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Medications for treating CRS and ICANS

Published
Topics: Advanced therapy medicinal productsCautions and contraindicationsGuidancePrescribing

Guidance on which medications to use when treating CRS and ICANS.

This article forms part of a series
  1. Understanding acute CAR-T cell therapy toxicities in adults
    1. Diagnosis and management of cytokine release syndrome (CRS)
    2. Diagnosis and management of ICANS
    3. Medications for treating CRS and ICANS

Summary of treatment options

Tocilizumab and corticosteroids form the basis of treatment of acute CAR-T cell side effects. Tocilizumab is only licensed to treat CRS, and should not be used for ICANS (unless concurrent CRS).

Dexamethasone is the corticosteroid of choice for both CRS and ICANS. High dose corticosteroids should be used for the shortest time possible.

Anakinra is recommended for the management of refractory CRS and ICANS. Its use is off-label and unfunded. It is preferred over methylprednisolone to reduce high dose steroid use. This may differ from product SmPCs.

It is important to have access to anakinra for refractory cases due to the life-threatening consequences of CAR-T cell therapy toxicities.

In very severe and refractory cases when the advised treatment options have been exhausted, alternative options should be explored in discussion with the CAR-T multidisciplinary team (MDT).

Alternative treatment options include anti-cytokine and immunosuppressive treatments such as siltuximab, etanercept, dasatinib, ruxolitinib. These treatments are off-label and should only be used in line with Trust formulary processes.

Where possible, patients should be enrolled into clinical trials for managing CAR-T cell toxicities.

Medication information tables

Additional information to support prescribing, preparation and administration of CRS and ICANS treatments.