Experts gather for a roundtable on the rare, delayed toxicities associated with ciltacabtagene autoleucel in relapsed/refractory multiple myeloma.
Sara Scott, PharmD, BCOP, is an oncology plinical Pharmacy specialist at Emory Healthcare, Winship Cancer Institute.
Rebecca Gonzalez, PharmD, BCOP, FASTCT, is a clinical pharmacist specialist in bone marrow transplant and cellular therapy at Moffitt Cancer Center.
Emma Uchida, PharmD, MBA, BCOP, ematology/bone marrow transplant clinical pharmacist at the University of Kentucky Markey Cancer Center.
As ciltacabtagene autoleucel (cilta-cel, Carvykti; Janssen) use has expanded in relapsed/refractory multiple myeloma following its CARTITUDE-1 and CARTITUDE-4 approvals, a distinct set of delayed, atypical toxicities has emerged beyond the expected cytokine release syndrome and ICANS.
Three clinical pharmacists—Sara Scott, PharmD, BCOP, Emma Uchida, PharmD, MBA, BCOP, and Rebecca Gonzalez, PharmD, BCOP,—walk through 3 of these complications in turn: cranial nerve palsies (median onset ~3 weeks, generally steroid-responsive), IEC-associated parkinsonism/neurotoxic treatment-emergent symptoms (delayed onset up to 3 months, poorly responsive to levodopa/carbidopa), and immune effector cell-associated enterocolitis (onset 1–3+ months, the most severe of the 3 with high mortality). Throughout, they tie each toxicity back to shared risk drivers — elevated IL-6, tumor burden, absolute lymphocyte count, and CAR-T expansion/persistence.
The conversation moves into concrete, institution-specific management: corticosteroid dosing and IVIG for cranial nerve palsies; the shift away from dopaminergic agents toward steroids, intrathecal chemotherapy, high-dose cyclophosphamide, and low-dose ruxolitinib for parkinsonism; and a stepwise escalation from steroids to GI biologics (infliximab, vedolizumab), ruxolitinib, and cyclosporine for enterocolitis. The panel also discusses ALC-based monitoring thresholds and prophylactic dexamethasone strategies as emerging tools for risk stratification and closes by looking ahead to how earlier-line use of cilta-cel (eg, CARTITUDE-6) may reshape this toxicity landscape—underscoring the pharmacist's role in early recognition, interdisciplinary coordination, and navigating off-label therapy access.
