J Clin Oncol. 2021; CRS Management Guideline

Cytokine Release Syndrome (CRS) Overview

• The first symptom of CRS is often fever.
• A key biomarker used as a surrogate for IL-6 activity in CRS is serum C-reactive protein (CRP).

Management of CRS

• Common approaches to managing CRS include monitoring and supportive care.
• Organ systems affected in CRS can include the neurological system, in addition to fever and hypotension.
• Immune effector-associated neurotoxicity syndrome (ICANS) is characterized by encephalopathy and neurological impairments.

Early Management Interventions

• Early intervention in CRS management often includes the administration of tocilizumab.
• Due to steroid use in CRS management, additional medications like short-acting insulin may be recommended to manage hyperglycemia.

Case Study Insights

• Initial treatment for grade 1 CRS included observation and supportive care.
• The Advanced Practice Provider (APP) played a crucial role in coordinating care and monitoring symptoms in the case study.
• A chest x-ray performed in the case study resulted in findings that were consistent with CRS-related effects, although specific details are not provided.
• An absolute neutrophil count (ANC) level of less than 500 prompted the initiation of empiric IV antibiotics in the case study.
• An additional symptom that led to consultation with the infectious disease team was a significant drop in blood pressure.

CRS Grading and Management Guidelines

• The most severe grade of CRS is Grade 4 according to the CTCAE v5.0 grading system.
• Management of Grade 2 CRS involves the use of tocilizumab along with close monitoring.
• Grade 3 CRS is marked by symptoms such as high fever, hypotension, or severe fatigue.
• If hypotension persists in Grade 2 CRS after the administration of tocilizumab and fluid boluses, vasopressors may be considered.
• For Grade 3 CRS, additional actions include potential escalation of care and consideration for ICU admission.
• Grade 4 CRS should be managed as refractory if it does not respond to initial treatments and support measures.