CAR-T Outpatient?

[Shan, RN]

Hi all! I was at a vendor fair a few weeks ago for my local ONS chapter, and I was speaking with a drug rep for Carvykti. She said that 40% of patients receiving the therapy are now getting it outpatient. I was shocked - I had no idea that outpatient CAR-T administration was a thing. My practice has started administering bi-specific T-cell engagers (Blincyto, Tecvayli, Epkinly, etc), but we strictly adhere to the inpatient observation recommendations; however, I was under the impression that anything CAR-T was totally inpatient due to the higher likelihood of CRS and neuro tox. I was wondering if anyone on here has any experience with giving CAR-T outpatient - how do you monitor for complications? Do patients manage low-grade CRS at home?

[Jessdee223]

Hi there!

a lot of car t is done outpatient, at least in my experience in Massachusetts. If you think of the volume of patients receiving treatment and the limited number of inpatient beds, there's no way to accommodate everyone inpatient at the same time.

remember, the median CRS onset for cilta-cel is around 7 days. At my facility, the majority of cilta-cel patients get outpatient treatment, follow up with us daily through count recovery, and are told to notify us of any crs. If it's early onset or at least Grade 2, we get them if for toci, dex, anakinra, etc. we have an infusion room that is held in prep for this.

[Shan, RN]

Wow, so good to know! Here in Fort Worth, we don't really do CAR-T or ASCT - all the patients go to Dallas for those things. However we have quite a thriving medical district here in FW so I think a lot of the pharmaceutical companies are really wanting to get more hospitals onboard with offering those treatments. So even Grade 2 CRS is managed outpatient? We do have toci at my clinic because we are delving into the BiTEs but we've yet to have any instances of short-onset CRS (knock on wood) and patients go to the hospital for obs, anyways. Do you manage low-grade neurotoxicity outpatient? Thanks so much for the reply!

[Jessdee223]

For standard of care CAR products, grade 2 definitely requires toci, so that required inpatient administration per the REMS program. I just meant that, grade 1 doesn't always require toci. Usually is someone presents with grade 1 within 72 hours of cell infusion, if it's persistent grade 1, or grade 1 in the setting of massive CAR expansion (I once saw someone absolute lymphocyte counts quadruple within 48 hours), that usually calls for toci. 
the rationale at my facility is, most patients will require an inpatient stay at some point. If you can maximize their time outpatient (home, if appropriate), that improves their quality of life and overall bodes well for their recovery.

[Jessdee223]

And you're welcome!

[DavidFR, BSN, MSN, RN]

Car-T as an outpatient, Wow - can't even imagine that, frankly.

I hear clinical trials are starting using Car-T for solid tumours. Anybody else involved in that?

[Jessdee223]

A lot of CAR-T and BMT is being done outpatient with daily follow-ups. 
my hospital is doing CAR-T for glioblastoma as wall. Really gnarly