(NSO-01) Supporting the Shift: Inpatient Review of BCMA CAR-T Therapy in Multiple Myeloma Reveals Early Safety and Feasibility for a Nurse Lead Outpatient Model of Care
CAR-T Cell Therapy Nurse Practitioner Candidate The Alfred Hospital Melbourne, Victoria, Australia
Introduction: BCMA-directed CAR-T therapy has significantly improved outcomes for patients with multiple myeloma (MM). Due to the potential for immune-mediated toxicities, the CAR-T infusion is traditionally administered in the inpatientsetting. However, products utilisinga 4-1BB co-stimulatory domain are often associated with a more delayed onset of toxicity, suggesting early post-infusion monitoring may be safely managed outside of hospital. This abstract presents a retrospective analysis of inpatient CAR-T recipients and proposes a model for outpatient care led by Advanced Practice Nurses(APNs).
Methods: A retrospective review of clinical outcomes of 37MM patients who received BCMA-targeted CAR-T therapy as inpatients was conducted. Two patients were classified as high risk and were admitted at the commencement of lymphodepleting chemotherapy (LDC); these patients were excluded from the outpatient feasibility analysis.All remainingpatients (n=35) were monitored closely for cytopenias and immune-related adverse events following LDC and CAR-T infusion. The focus of this analysis was to evaluate the incidence and timingof early complications (Day 0 to Day +4post-infusion), with the aim of informing a future outpatient delivery model.
Results: The median time to onset of cytokine release syndrome (CRS) was Day +7 (range: Day +5 to +13), and the median onset of immune effector cell-associated neurotoxicity syndrome (ICANS) was also Day +7. No patients experienced severe immune-related toxicities or cytopenias that would have necessitatedan emergency department presentation or unplanned escalation of care within the first five days post-infusion. BCMA CAR-Twas associated with a delayed immune activation profile, with the majority of CRS and ICANS cases occurring on or after Day +5 compared to Lymphoma groups utilising a CD28 costimulatory domain. Cytopenias varied and were managed effectively with supportive care therapies.
Conclusions: This inpatient analysis demonstrates that early complications following BCMA-directed CAR-T cell therapy are infrequent and clinically manageable, with most immune-mediated toxicities emerging after Day +5. These findings support a proposed hybrid model of care in which patients are managed in the outpatient setting from the commencement of LDC through to Day +4. During this period, patients should undergo daily ambulatory assessmentsincluding blood tests, ICE scoring, and neurological evaluations, coordinated and overseen by an APN with specialisedexpertise in early toxicity detection and supportive care management. Patients would then transition to inpatient admission on Day +4 for high-risk monitoring during the peak period of CAR-T expansion. This model is dependent on the patient having a 24/7 caregiver, access to a dedicated haematology on-call service, and being located in close proximity to the treatingcentre. It prioritises patient safety while promoting healthcare sustainability and a more patient-centred approach to CAR-T delivery.
