This protocol applies to patients with multiple myeloma who develop immune effector cell-associated neurotoxicity syndrome (ICANS) following immune effector-based therapy. ICANS is a pathological process affecting the central nervous system that arises from the activation or deployment of endogenous or infused T cells and/or other immune effector cells administered as part of treatment.
Management of severe ICANS in this setting is structured around a corticosteroid-based approach, with a defined escalation pathway for cases that do not respond. Where cerebrospinal fluid pressure is elevated, specific interventional measures are indicated. The complete stepwise protocol — including agents, escalation criteria, sequencing, and adjunctive measures — is available via the full regimen below.
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 4 ICANS, give dexamethasone (20 mg every 6 h). If ICANS is dexamethasone-refractory, consider high-dose methylprednisolone (2 mg/kg every 12 h).
If still refractory, consider alternative therapies including lymphodepletion with cyclophosphamide or other drugs [panel consensus; IV, C].
If CSF pressure >20 mmHg, drain CSF to <20 mmHg via an Ommaya device [panel consensus, V, C].
DOI: 10.1038/s41571-025-01041-x
View source ↗