CAR-T and checkpoint inhibitors: toxicities and antidotes in the emergency department

Abstract

Introduction

New cancer treatments with immunotherapy have led to unique toxicities affecting cancer patients. As cancer-related visits to the emergency department increase, the emergency physician and the medical toxicologist should be aware of immunotherapy-related toxicities. In this review we discuss immune related adverse events (irAEs) from chimeric antigen receptor T (CAR-T) cell therapy and immune checkpoint inhibitors (ICI).

Discussion

While presentation of the irAEs may mimic common conditions, it is important to recognize them as they may be life-threatening. A thorough history and examination of the patient, including their cancer treatment history in the past year is crucial. Conditions such as cytokine release syndrome (CRS) and immune effector cell associated neurotoxicity syndrome (ICANS), which can occur after CAR-T treatment, can progress rapidly to a fatal outcome if not recognized and managed in a timely manner. ICI can affect any organ system and irAEs may present like a typical autoimmune disease of the affected organ. While most of the irAEs we discuss in this review will benefit from treatment with glucocorticoids, it is important to know the grade of the condition, as it will determine the treatment dose, route and further management considerations.

Conclusion

Patients experiencing irAEs from ICI and CAR-T can present with subtle symptoms that can rapidly progress if not recognized early. The emergency physician and the medical toxicologist should keep in mind these toxicities and the patient’s oncologic history to adequately recognize and manage these conditions.

Keywords:

• CAR-T
• Immunotherapy
• ICI
• ICANS
• CRS
• emergency department

Acknowledgements

We would like to thank David Aten and the creative communications department at MD Anderson Cancer Center for production of Figure 1. We created Figure 2 using Biorender.com.

Disclosure statement

DNL has received compensation as a content expert for the Society of Immunotherapy of Cancer (SITC). DNL has also received compensation for multiple immunotherapy toxicity presentation via PeerView Institute for Medical Education. SS has no conflicts of interest to declare.

Additional information

Funding

This review is supported in part by the National Institutes of Health through MD Anderson’s Cancer Center Support Grant [CA016672].