Monitoring Severe Adverse Effects of Bispecifics in Multiple Myeloma

Education and attentive monitoring of adverse effects (AEs) are essential to safe use of BCMA-targeted bispecific antibodies in patients with multiple myeloma, according to Lisa Hwa Christenson, APRN, DNP, CNP, FAPO.

Christenson, a nurse practitioner and assistant professor at the Mayo Clinic College of Medicine in Rochester, Minnesota, shared insights during an interview with Oncology Nursing News after moderating a Case-Based Roundtable with peer advanced practice providers (APPs) on the clinical use of BCMA-directed bispecific antibodies, such as teclistamab (Tecvayli), elranatamab (Elrexfio), and linvoseltamab (Lynozyfic), in multiple myeloma.

Christenson emphasized that cytokine release syndrome (CRS) and immune effector cell–associated neurotoxicity syndrome (ICANS) remain key risks with bispecific antibody therapy. While the incidence of CRS often decreases once patients transition from step-up dosing in academic centers to community clinics, it is essential that APPs and nurses remain alert to symptoms, understand grading, and follow established protocols.

She noted that fever is a defining feature of CRS but stressed the importance of ruling out infection and cardiac causes before attributing symptoms solely to treatment. Supportive care, hydration, and antipyretic management are crucial, with therapies such as tocilizumab (Actemra) and corticosteroids used according to institutional guidelines. Ongoing patient and staff education ensures prompt recognition and safe management of these potentially serious events.

Transcript

Educating is very important. We talk about both the CRS and ICANS—they can be very immediate. If the patients are choosing to get step-up dosing in an academic center, by the time they’re being transitioned into the community oncology [clinic], then the incidence for CRS is much lower.

Many of the centers are developing their own protocol to start step-up dosing in their own practice in the community setting. Then, it’s very important to educate and for the team to monitor what the symptoms of CRS are and how you grade it.

Anyone with CRS has to have a fever, and then it depends on the severity, whether they need [blood pressure support] and what degree of oxygen for respiratory support, so hydrating the patients and managing the fever.

The other very important thing is when patients present with the fever. We all know infection is a very common situation, so you have to make sure: you cannot just assume this is CRS. You must rule out infection if a patient presents with tachycardia or are hypotensive, so then you must rule out any cardiac causes for the symptoms as well. Tocilizumab has been reported to be very effective in managing CRS as well. In our center, we have a protocol based on the degree of CRS and ICANS to see who’s eligible for the tocilizumab and who’s eligible for the steroid.

This transcript has been edited for clarity and conciseness.