Synopsis
Explain referral, manufacture and delivery of CAR-T and other cellular therapies, coordinate bridging and lymphodepletion, and recognise cytokine-release, neurotoxic, infective and prolonged haematological complications.
- CAR-T therapy uses genetically modified autologous T cells to recognise a tumour surface antigen and is delivered only through commissioned specialist centres.
- The pathway includes eligibility, cell collection, manufacture, bridging treatment where needed, lymphodepletion, infusion and prolonged toxicity surveillance.
- Manufacturing time and failure are clinically important; disease can progress before infusion and bridging therapy must not compromise organ reserve or cell delivery.
- Cytokine-release syndrome causes fever, hypotension and hypoxia, usually early, but sepsis has overlapping physiology and requires cultures and empirical antimicrobials.
- Immune-effector-cell-associated neurotoxicity can cause inattention, dysgraphia, aphasia, tremor, seizure or cerebral oedema and may occur with or after cytokine-release syndrome.
- Tocilizumab is used for protocol-defined significant cytokine-release syndrome. For significant ICANS, contact the CAR-T centre and start centre-protocol corticosteroid without delay when indicated; fever alone is not a reason for unstructured empirical steroid dosing.
- Prolonged cytopenia, hypogammaglobulinaemia, opportunistic infection, tumour lysis and secondary malignancy require months to years of follow-up.
- Patients and carers need accommodation, transport, emergency contact and a written alert because safe treatment depends on rapid return to the specialist centre.
Key red flags
Seizure, motor deficit, reduced consciousness or features of cerebral oedema require immediate neurocritical and CAR-T-centre management.
Investigation priorities
Confirm commissioned indication, response need and physiological fitness before collection.
Management branches
A patient may meet a commissioned CAR-T indication.
- Refer early to the designated centre with pathology, treatment history, disease burden, performance and organ data.
- Confirm consent, caregiver and travel arrangements, infection screening and leukapheresis suitability while planning a realistic bridging strategy.
- Preserve chain of identity through collection and manufacture and create a contingency if product or disease control fails.
Key medicines
Tocilizumab for CAR-T cytokine-release syndromeFor adults weighing at least 30 kg, give 8 mg/kg intravenously over 60 minutes, maximum 800 mg per dose. If there is no clinical improvement, up to 3 additional doses may be given at intervals of at least 8 hours, within the CAR-T centre protocol.Do not let cytokine-directed treatment delay cultures, antimicrobials or shock care. Monitor liver, blood count and infection; isolated ICANS may not respond, and significant neurotoxicity requires its own protocol-directed treatment.