Clinical factors that influence brexu-cel treatment
| Clinical scenario . | Brexu-cel considerations . |
|---|---|
| Recent CNS disease that has cleared to CNS-1 | • CART19 products in general have been shown to cross the BBB and treat the CNS compartment making brexu-cel an attractive choice • There are no data on safety of brexu-cel in patients with active CNS disease |
| HSCT not possible or desirable • Relapse occurs after prior HSCT • High risk for complications from HSCT • No donor option • Patient defers HSCT | • Brexu-cel is an attractive choice given mDOR of 12.8 mo both with and without consolidative HSCT • Unknown if brexu-cel (without bridging to HSCT) will be a curative approach to a subset of patients with r/r ALL. Further data with longer follow-up needed |
| Rapidly progressive disease | • Identifying a clinical and logistical window for leukapheresis may be challenging for brexu-cel • Consider other approaches if appropriate (such as inotuzumab) • Patients with high disease burden and circulating disease however have had brexu-cel successfully manufactured and been successfully treated |
| Any patient with high disease burden | • An attempt to minimize disease burden prior to infusion should be made in patients receiving brexu-cel with high disease burden to minimize toxicity |
| Frail or older patient with comorbid disease and high disease burden | • Patient may not tolerate anticipated severe CRS or ICANS with brexu-cel. Consider alternative approaches |
| Frail or older patient with comorbid disease and minimal disease burden | • Patient is likely to do well with blinatumomab, inotuzumab, and brexu-cel • With brexu-cel, side effects of CRS and ICANS are anticipated to be lower with lower disease burden but need to consider toxicity of chemotherapy conditioning as well when considering options |
| Clinical scenario . | Brexu-cel considerations . |
|---|---|
| Recent CNS disease that has cleared to CNS-1 | • CART19 products in general have been shown to cross the BBB and treat the CNS compartment making brexu-cel an attractive choice • There are no data on safety of brexu-cel in patients with active CNS disease |
| HSCT not possible or desirable • Relapse occurs after prior HSCT • High risk for complications from HSCT • No donor option • Patient defers HSCT | • Brexu-cel is an attractive choice given mDOR of 12.8 mo both with and without consolidative HSCT • Unknown if brexu-cel (without bridging to HSCT) will be a curative approach to a subset of patients with r/r ALL. Further data with longer follow-up needed |
| Rapidly progressive disease | • Identifying a clinical and logistical window for leukapheresis may be challenging for brexu-cel • Consider other approaches if appropriate (such as inotuzumab) • Patients with high disease burden and circulating disease however have had brexu-cel successfully manufactured and been successfully treated |
| Any patient with high disease burden | • An attempt to minimize disease burden prior to infusion should be made in patients receiving brexu-cel with high disease burden to minimize toxicity |
| Frail or older patient with comorbid disease and high disease burden | • Patient may not tolerate anticipated severe CRS or ICANS with brexu-cel. Consider alternative approaches |
| Frail or older patient with comorbid disease and minimal disease burden | • Patient is likely to do well with blinatumomab, inotuzumab, and brexu-cel • With brexu-cel, side effects of CRS and ICANS are anticipated to be lower with lower disease burden but need to consider toxicity of chemotherapy conditioning as well when considering options |
BBB, blood-brain barrier.