Supportive care guidelines for patients receiving CAR T cells
| Toxicity . | Preventive and supportive care interventions . |
|---|---|
| Constitutional | Administer acetaminophen for symptomatic management of fevers in patients with normal hepatic function; |
| Provide cooling blankets for fevers >40°C; | |
| Avoid corticosteroids and NSAIDs; and | |
| Avoid meperidine | |
| Cardiovascular | Stop or taper antihypertensive medications prior to cell infusion; |
| Monitor vital signs at least every 4 h on an inpatient unit for at least 9 d following infusion; | |
| Monitor vital signs every 2 h in patients with fevers and tachycardia; | |
| Initiate replacement IV fluids for patients with poor oral intake or high insensible losses to maintain net even fluid balance; | |
| Administer IV fluid boluses for patients with SBP less than their preinfusion baseline: | |
| Patients with a SBP <80% of their preinfusion baseline and <100 mm Hg receive a 1 liter normal saline bolus | |
| Patients with a SBP <85 mm Hg receive a 1 liter normal saline bolus regardless of baseline blood pressure | |
| Patients receiving >1 IV fluid bolus for hypotension or patients in the ICU for toxicity management have a serum troponin drawn, and an ECG and an echocardiogram performed to evaluate for cardiac toxicity; and | |
| Patients with hypotension are initiated on vasopressor support. Norepinephrine is the preferred first-line vasopressor | |
| Infectious disease | Initiate prophylactic antimicrobials, such as trimethoprim-sulfamethoxazole, for Pneumocystis prophylaxis prior to conditioning chemotherapy; |
| Initiate prophylactic antimicrobials, such as acyclovir or valacyclovir, for herpes virus prophylaxis prior to conditioning chemotherapy; and | |
| All patients with fevers and neutropenia have blood cultures drawn and broad-spectrum antibiotic coverage initiated | |
| Hematologic | Initiate allopurinol for TLS prophylaxis in patients without a contraindication prior to conditioning chemotherapy; |
| Transfuse packed red cells for goal hemoglobin of ≥8.0 g/dL; | |
| Transfuse platelets for a goal platelet count of ≥20 000/μL; | |
| Monitor complete blood count with differential twice daily. When ANC decreases to <500/μL, initiate filgrastim support. Continue until ANC increases to ≥1500 μL; | |
| Transfuse fresh frozen plasma with a goal of normalization of PTT in patients with a PTT >1.5-fold above the upper limit of normal; and | |
| Transfuse cryoprecipitate to maintain fibrinogen of ≥100 mg/dL. If patient is bleeding, a higher level of fibrinogen should be maintained | |
| Neurologic | The nursing staff conducts focused neurologic examinations every 8 h in patients experiencing neurologic toxicity; |
| Perform brain MRI in any patient experiencing neurologic toxicity; | |
| Perform lumbar puncture to evaluate for infectious pathogens, cytokine levels, and CAR T-cell levels in patients experiencing neurologic toxicity whenever feasible; | |
| Request a neurology consultation for any patient experiencing neurologic toxicity; and | |
| Standard antiepileptic medications are used for patients having active seizures. We do not use prophylactic antiepileptic medications |
| Toxicity . | Preventive and supportive care interventions . |
|---|---|
| Constitutional | Administer acetaminophen for symptomatic management of fevers in patients with normal hepatic function; |
| Provide cooling blankets for fevers >40°C; | |
| Avoid corticosteroids and NSAIDs; and | |
| Avoid meperidine | |
| Cardiovascular | Stop or taper antihypertensive medications prior to cell infusion; |
| Monitor vital signs at least every 4 h on an inpatient unit for at least 9 d following infusion; | |
| Monitor vital signs every 2 h in patients with fevers and tachycardia; | |
| Initiate replacement IV fluids for patients with poor oral intake or high insensible losses to maintain net even fluid balance; | |
| Administer IV fluid boluses for patients with SBP less than their preinfusion baseline: | |
| Patients with a SBP <80% of their preinfusion baseline and <100 mm Hg receive a 1 liter normal saline bolus | |
| Patients with a SBP <85 mm Hg receive a 1 liter normal saline bolus regardless of baseline blood pressure | |
| Patients receiving >1 IV fluid bolus for hypotension or patients in the ICU for toxicity management have a serum troponin drawn, and an ECG and an echocardiogram performed to evaluate for cardiac toxicity; and | |
| Patients with hypotension are initiated on vasopressor support. Norepinephrine is the preferred first-line vasopressor | |
| Infectious disease | Initiate prophylactic antimicrobials, such as trimethoprim-sulfamethoxazole, for Pneumocystis prophylaxis prior to conditioning chemotherapy; |
| Initiate prophylactic antimicrobials, such as acyclovir or valacyclovir, for herpes virus prophylaxis prior to conditioning chemotherapy; and | |
| All patients with fevers and neutropenia have blood cultures drawn and broad-spectrum antibiotic coverage initiated | |
| Hematologic | Initiate allopurinol for TLS prophylaxis in patients without a contraindication prior to conditioning chemotherapy; |
| Transfuse packed red cells for goal hemoglobin of ≥8.0 g/dL; | |
| Transfuse platelets for a goal platelet count of ≥20 000/μL; | |
| Monitor complete blood count with differential twice daily. When ANC decreases to <500/μL, initiate filgrastim support. Continue until ANC increases to ≥1500 μL; | |
| Transfuse fresh frozen plasma with a goal of normalization of PTT in patients with a PTT >1.5-fold above the upper limit of normal; and | |
| Transfuse cryoprecipitate to maintain fibrinogen of ≥100 mg/dL. If patient is bleeding, a higher level of fibrinogen should be maintained | |
| Neurologic | The nursing staff conducts focused neurologic examinations every 8 h in patients experiencing neurologic toxicity; |
| Perform brain MRI in any patient experiencing neurologic toxicity; | |
| Perform lumbar puncture to evaluate for infectious pathogens, cytokine levels, and CAR T-cell levels in patients experiencing neurologic toxicity whenever feasible; | |
| Request a neurology consultation for any patient experiencing neurologic toxicity; and | |
| Standard antiepileptic medications are used for patients having active seizures. We do not use prophylactic antiepileptic medications |
These are the current treatment guidelines used for adult patients at the NCI Experimental Transplantation and Immunology Branch.
ANC, absolute neutrophil count; ICU, intensive care unit; MRI, magnetic resonance imaging; NSAIDs, nonsteroidal anti-inflammatory agents; SBP, systolic blood pressure.