Toxicities
This CAR-T related toxicity is characterized by temperature greater than 38 degrees Celsius, progressing to hypotension and hypoxia
Cytokine Release Syndrome
This medication is given to CAR-T patients for treatment of severe CRS. It is an anti-interleukin 6 inhibitor originally used for the treatment of juvenile idiopathic arthritis. This medication must be protected from light, and two doses must be present on site for each CAR-T patient undergoing therapy.
Tocilizumab
This integumentary assessment finding is characterized by clusters of non-blanching, flat, red, pinpoint dots often found on the extremities, trunk, and mucous membranes. It is associated with hemorrhage into the dermis.
Petechiae
This is a type of intracellular protein that stores iron and releases it in a controlled fashion. It is used to monitor success of therapeutic phlebotomies in certain patient populations. In CAR-T patients, elevation of this level can be a predictive indicator of CRS.
Ferritin
After infusion, how long will CAR-T recipients be restricted from driving
8 weeks
This CAR-T related toxicity is characterized by confusion, difficulty recalling words or phrases, alterations in motor function, decreased levels of consciousness progressing to seizures and cerebral edema
IEC-Associated Neurotoxicity Syndrome (ICANS)
This medication or group of medications may be used to treat or prophylactically prevent severe CRS in patients receiving CAR-T therapy associated with higher rates of CRS. It is also used to treat ICANS in CAR-T patients.
Corticosteroids
If a CAR-T patient taking oral steroids presents with creamy, white lesions on the tongue, inner cheeks, or roof of the mouth, this condition is suspected
Oral Candidiasis/Thrush
This is a protein produced by the liver. This protein increases following interleukin-6 (cytokine) secretion by macrophages and T cells. It is associated inflammatory conditions like R.A., Lupus, Inflammatory Bowel Disease, and Sepsis. In CAR-T patients, elevation of this level can be a predictor of CRS.
After a patient's primary hematologist refers them to the CAR-T specialist, additional testing is ordered to determine patient fitness for treatment. This workup includes assessment of organ function, comorbidities, performance status, and screening for viral infections. This step in the CAR-T journey is known as...
Evaluation
This is a complication associated with severe CRS and characterized by leakage of plasma out of the blood vessels into muscle, tissue, and the extravascular space. Hallmark symptoms are hypotension, ascites, peripheral edema, pleural effusion, dyspnea and bibasilar crackles
Capillary Leak Syndrome
These two chemotherapies are given in combination as a part of lymphodepletion to help prepare the host for the infusion of CAR-T cells. It helps to reduce endogenous T cells and cytokines to prevent interference with CAR-T cell function. Hint: one of these is an antimetabolite and the other is a nitrogen mustard
Fludarabine and Cyclophosphamide
The risk of this cardiac/EKG abnormality increases if the patient is on an "Azole" antifungal and Zofran at the same time. If this condition progresses excessively, it can predispose the heart to the development of re-entry tachycardias and severe arrhythmias like Torsade de Pointes
This is a type of antibody representing approximately 75% of serum antibodies in humans. They are released by plasma B cells, and CAR-T patients are at risk for suppression of this antibody's production. Normal range is (700-1600mg/dL). Levels will be drawn at count recovery and then weekly or every other week post-count recovery.
Immunoglobulin G (IgG)
There are currently 6 FDA-approved commercial CAR-T products for the treatment of these 5 hematologic malignancies
Commercial CAR-T products: Breyanzi, Yescarta, Tecartus, Carvykti, Abecma, Kymriah
Multiple Myeloma, Diffuse Large B Cell Lymphoma, Follicular Lymphoma, Mantle Cell Lymphoma, B Cell Acute Lymphoblastic Leukemia
This CAR-T related complication is characterized by low serum antibody levels. It occurs when anti-CD19 and anti-CD20 CAR-T cells attack and kill healthy CD19 and CD20 B-lymphocytes. IVIG replacement may be included in treatment of this condition.
B-Cell Aplasia/Hypogammaglobulinemia
This is a medication the patient will start on Day 0 or earlier if their ANC is <500/mm3. This medication is taking by mouth once daily, but it is associated with an increased risk for acute tendinopathy with or without tendon rupture. The patient should avoid dairy products for 2 hours before or after taking this medication.
Levofloxacin
Tumor Lysis Syndrome is a life-threatening condition caused by massive tumor cell lysis with the release of large amounts of intracellular substances and metabolites into systemic circulation. What four lab abnormalities are indicators of TLS?
Hyperkalemia
Hyperphosphatemia
Hyperuricema
Hypocalcemia
Clinical abnormalities: AKI, dysrhythmia, muscle cramps and weakness, seizures
This level will be drawn at count recovery and then at provider discretion for suspected reactivation. It is used to track reactivation of this latent virus that lives in host B cells. Reactivation is characterized by lymph node enlargement, spleen enlargement, night sweats, malaise, fatigue and sore throat. Rituximab is the treatment for its reactivation.
Epstein-Barr Virus (EBV DNA PCR)
This is a procedure that involves the removal of whole blood, which is then separated into different layers by centrifugation using specific gravity of cellular components. Remaining blood components are then returned to the body. This procedure collects mononuclear cells, which are then isolated into specific leukocytes in a cell processing lab.
Apheresis/leukapheresis
This is a rare but often fatal condition caused by dysregulated immune activity resulting in malignant inflammation and multi-organ failure. It leads to excessive white blood cell build and destruction of other blood cells. Symptoms include fever, splenomegaly, hepatomegaly, weight loss, lymphadenopathy, fever, jaundice, and abdominal pain.
Hemophagocytic Lymphohistiocytosis (HLH) or Macrophage Activation Syndrome (MAS)
CAR-T patients will start this medication on Day + 30 and continue until their CD4+ T cell count is >200/mm3. It is given for the prevention of Pneumocystis Jirovecii Pneumonia. Patient teaching should include avoiding sun exposure and taking the medication with food or milk. For patients with an allergy to this medication, Dapsone 100mg PO is the alternative.
Bactrim (Sulfamethoxazole/trimethoprim 400/80mg PO daily)
A patient with DLBCL who is D+2 from Yescarta with an ANC of 800/mm3 comes to the clinic and reports chills, dizziness, and shortness of breath. His vitals are as follows: T 38*C (100.4*F), HR 120, BP 92/60, and O2 sat 89% on RA. You administer a 1000mL NS bolus and apply 2L NC to the patient. BP improves to 104/70 and oxygen is 94%. What grade of CRS is this patient experiencing? What other oncologic emergency is this patient experiencing?
Grade 2 CRS/Neutropenic Fever
This level will be drawn at count recovery and then at provider discretion for suspected reactivation. This level will monitor for reactivation of a latent herpesvirus that lies dormant in bone marrow stem cells and myeloid cells. It is a common virus affecting 60-70% of adults. Reactivation can lead to pneumonitis, gastroenteritis, retinitis, hepatitis, and encephalitis.
Cytomegalovirus (CMV DNA PCR)
For patients experiencing CRS, what is the maximum dosage of Tocilizumab
800mg