Reducing Hospitalization Without Compromising Safety: Step-Up Dosing Criteria and Best Practices in Myeloma

In this episode, 'Reducing Hospitalization Without Compromising Safety: Step-Up Dosing Criteria and Best Practices in Myeloma,' the oncology pharmacists explore the following questions:

Recent educational programs reported significant variability across institutions in how long patients are hospitalized for step-up dosing. What should be driving that decision, and how are more experienced centers thinking about it?

What criteria does your institution use to determine inpatient versus outpatient step-up dosing eligibility?

The panelists examined what is driving the significant variability in step-up dosing hospitalization practices across institutions, noting that centers newer to bispecific antibody administration tend to default to package insert guidance, which can result in patients spending up to nine or more days inpatient depending on the product and observation schedule, while more experienced centers are increasingly drawing on real-world evidence to safely compress these timelines, including published data supporting abbreviated step-up schedules for teclistamab that have demonstrated equivalent safety with shorter hospitalization. The discussion also outlined the specific patient and disease characteristics that institutions are using to determine outpatient versus inpatient eligibility, with outpatient candidates generally defined as patients who can remain within a 30-minute radius of the treating center, have a dedicated caregiver available throughout the step-up period, and do not present with high-risk disease features, populations for whom inpatient observation is preferred given the heightened risk of severe CRS manifestations. The panelists further emphasized that as real-world experience accumulates and clinical comfort with CRS and neurotoxicity management grows, the field is moving steadily toward broader outpatient step-up dosing while geographic proximity to a CRS-capable emergency facility remains a non-negotiable safety requirement that continues to limit outpatient eligibility for patients in rural or underserved areas.

Throughout the conversation, the experts provide a comprehensive reflection on the field and the factors that may shape how clinicians approach care moving forward.

The next episode in this series, 'Getting CRS Right: Clinical Presentation, Appropriate Response, and Building a Well-Educated Care Team,' features the panelists advancing their conversation on multiple myeloma and focusing on what Grade 1 CRS looks like in clinical practice versus how it tends to be managed in real-world settings, and how institutions are building the cross-team education infrastructure needed to ensure that nursing staff, emergency department teams, and inpatient providers respond appropriately when patients present with potential CRS symptoms.