Cytokine-release syndrome (CRS) is a recognised complication in multiple myeloma patients receiving CAR T-cell therapy or bispecific T-cell engager therapy. Prompt, graded management is essential to prevent haemodynamic deterioration.

Clinical Scenario

CRS in this setting is a systemic inflammatory response mediated by the activation of T lymphocytes, observed mainly after treatment with BCMA-targeted CAR T cells or bispecific T cell engagers. The presentation — fever, hypotension, and increased oxygen requirements — demands structured, escalating intervention guided by severity grade.

Treatment Approach — Grade 2 CRS

Management centres on haemodynamic stabilisation through intravenous fluid support, with early escalation to cytokine-directed therapy when fever or hypotension persists, and further escalation to corticosteroid therapy or intensive care when needed.

The complete graded algorithm — including specific agents, thresholds for escalation, and ICU transfer criteria — is in the full protocol.

References

DOI: 10.1038/s41571-025-01041-x

CRS is a systemic inflammatory response mediated by the activation of T lymphocytes, observed mainly after treatment with BCMA-targeted CAR T cells or bispecific T cell engagers.
For grade 2 CRS, give an intravenous fluid bolus of 500–1,000 ml to maintain a systolic blood pressure of >90 mmHg; administer tocilizumab (8 mg/kg infused over 1 h) early if fever of ≥39°C persists, or if hypotension persists after administration of the initial fluid bolus or initiation of oxygen supplementation [II, B].
If hypotension persists after administration of a second fluid bolus and tocilizumab, transfer to the intensive care unit for consideration of low-dose vasopressor therapy.
Add dexamethasone (10 mg intravenously every 6 h) if hypotension persists, especially after anti-IL-6 therapy [panel consensus; IV, C].

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Cytokine-Release Syndrome After CAR T-Cell or Bispecific T-Cell Engager Therapy in Multiple Myeloma

References