An Educational Program for Management of Adverse Outcomes in CAR-T Therapy

A poster presented during the Oncology Nursing Society 44^th Annual Congress discussed the results of implementing a Chimeric Antigen Receptor T-Cell (CAR-T) therapy education program to prepare nurses for possible adverse events associated with the therapy.

CAR-T therapy is used for patients who did not successfully achieve remission through other treatment strategies. The immunotherapy treatment works by genetically modifying a patient’s T-cells with a disarmed virus. When the new cells are reinfused back to the patient, they destroy cancer cells that express CD-19 antigens.

When treating patients with CAR-T therapy, it is important to be aware of possible outcomes, including Cytokine Release Syndrome (CRS) as well as severe neurotoxicities, which could be fatal; an intensive care unit (ICU) stay will likely be necessary. Therefore, part of the collaborative educational strategy addresses treatment guidelines in the event of neurotoxicities and/or CRS. Other key points of the program include an educational breakfast to introduce CAR-T therapy to inpatient and outpatient hematology/oncology staff, emergency department educator, and ICU staff; cooperation with pharmaceutical companies; mock run of CAR-T infusion from harvest to transfusion; and creation of unit policy and patient education.

The neurotoxicities treatment guidelines use a grading system with grades 2–4 to determine appropriate action. Symptoms associated with grade 2 include somnolence, confusion, or encephalopathy limiting instrumental activities of daily living (ADL), as well as dysphasia and impaired spontaneous communication. Grade 3 symptoms include obtundation, stupor, confusion, or encephalopathy limiting self-care ADL, as well as dysphasia and inability to read, write, or communicate intelligibly. Escalation to grade 4 is considered life-threatening and requires urgent intervention and mechanical ventilation. In grades 2 and 3, when concurrent CRS is not present, the recommendations are dexamethasone 10 mg IV Q6H and non-sedating anti-seizure medications. In grade 4 cases, in addition to the anti-seizure medication, it is also recommended to administer methylprednisolone 1,000 mg IV/day for three days, and then return to grades 2 and 3 treatment upon improvement.

Overall, following the CAR-T therapy education, nurses reported greater confidence regarding comfort and skill level in recognizing and treating CRS and neurotoxicities.

Lindsey Bashaw, RN; Pamela Bicknell, BSN, OCN, BMTCN, RN; Paul Muniz, BSN, BMTCN, RN; Kathryn Moreno, MSN, OCN, BMTCN, AOCNS, RN. Achieving Nurse readiness in the Administration, Management and Recognition of Adverse Reactions in Patients receiving Chimeric Antigen Reception T-Cell (CAR-T) Therapy