Treatment of Multiple Myeloma with Immune Effector Cell-Associated Neurotoxicity (ICANS)
Clinical Scenario
This protocol addresses patients with multiple myeloma who develop immune effector cell-associated neurotoxicity syndrome (ICANS) following immune effector-based therapy. ICANS is a CNS complication that can occur when immune effector cells are activated or deployed as part of treatment.
What is ICANS? ICANS is a pathological process affecting the central nervous system following administration of immune effector-based therapies. It results from the activation or deployment of endogenous or infused T cells and/or other immune effector cells. Recognition and grading of ICANS severity is essential to guide clinical management.
Management Approach (Partial Overview)
For grade 3 ICANS in this setting, the approach involves prompt initiation of corticosteroid therapy, with escalation to higher-intensity corticosteroid regimens or alternative immunomodulatory agents if there is no early response. Additional supportive measures may be indicated depending on intracranial pressure findings — the full stepwise algorithm, agent selection, and escalation criteria are detailed in the structured protocol.
References
DOI: 10.1038/s41571-025-01041-x
- 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.
- For grade 3 ICANS, start dexamethasone (10 mg every 6 h) and if no improvement is observed after 24 h, consider high-dose dexamethasone (20 mg every 6 h), high-dose methylprednisolone (1–2 g/day) and/or alternative agents such as anakinra [panel consensus; IV, C].
- Consider acetazolamide if cerebrospinal fluid (CSF) pressure is increased [panel consensus; IV, C].
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