Multiple myeloma
ICD-10 C90.0 · ICD-11 2A83.1

Managing ICANS in Multiple Myeloma After Immune Effector-Based Therapy

Patients with multiple myeloma who develop immune effector cell-associated neurotoxicity syndrome (ICANS) following immune effector-based therapy require prompt, structured clinical management. ICANS is a CNS complication driven by the activation or deployment of T cells and other immune effector cells, and its severity determines the therapeutic approach.

Clinical Scenario

This protocol addresses multiple myeloma complicated by immune effector cell-associated neurotoxicity syndrome (ICANS) arising after immune effector-based therapy. ICANS is a pathological process affecting the central nervous system that results from the activation or deployment of endogenous or infused T cells and/or other immune effector cells.

Treatment Approach (Partial Overview)

For Grade 2 ICANS, management centres on corticosteroid therapy. When response is inadequate after 48 hours, dose escalation or alternative immunomodulatory agents are considered — particularly in the setting of concurrent cytokine release syndrome. Anti-epileptic prophylaxis is also addressed as part of the structured approach. The complete sequencing, agent selection criteria, and full algorithm are in the protocol.

Instant Access to Structured Evidence-Based Regimens

References

  • ICANS is a pathological process affecting the CNS following administration of immune effector-based therapies that results from the activation or deployment of endogenous or infused T cells and/or other immune effector cells.
  • Those with grade 2 ICANS, especially if it is refractory to anti-IL-6 antibodies, should receive dexamethasone (10 mg every 6 h) or methylprednisone (1 mg/kg every 12 h) and, if the response is inadequate, the dexamethasone dose should be increased to 20 mg every 6 h.
  • If no improvement after 48 h, increase dexamethasone dose or administer alternative agents such as anakinra or tocilizumab in the concomitant presence of CRS [II, B].
  • Start non-sedating AEDs if not already being administered [II, B].

DOI: 10.1038/s41571-025-01041-x

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