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BsAb Safety in RRMM
Optimizing Bispecific Antibody Safety and Care Coordination in RRMM: The Oncology Pharmacist Perspective

Released: July 30, 2026

Syeda Saba Kareem
Syeda Saba Kareem, PharmD, BCOP
Sara A. Scott
Sara A. Scott, PharmD, BCOP
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Key Takeaways
  • Management of a patient experiencing CRS includes holding the bispecific antibody until resolution while giving supportive care and considering dexamethasone, tocilizumab, and/or methylprednisolone, depending on the grade, and an evaluation for an infection.
  • ICANS is assessed using the immune effector cell–associated encephalopathy score, where patients are asked a series of questions to look at their orientation, name objects, follow commands, and write a sentence.
  • Many patients with social support undergoing bispecific antibody step-up dosing are managed as outpatients with prophylactic tocilizumab, acetaminophen, monitoring plans, and instructions if CRS or ICANS symptoms occur.

Introduction
During a live webinar titled “Advancing Pharmacist Excellence in RRMM: Optimizing Bispecific Antibody Selection, Safety, and Patient Care,” Sara A. Scott, PharmD, BCOP, and Syeda Saba Kareem, PharmD, BCOP, discussed how pharmacists help monitor and manage patients with multiple myeloma (MM) who may experience toxicities from bispecific antibody (BsAb) treatment along with institutional strategies adopted to operationalize outpatient step-up dosing. In this commentary, they provide their answers to questions posed by the audience during the live event. You can find the related educational activities here.

In your experience, what are the most important factors to consider as a pharmacist evaluating what option would be best for a patient with MM who may be a candidate for BsAb therapy?

Sara A. Scott, PharmD, BCOP:
In my practice, the first factor I think about is the patient’s preference. Other factors I consider next are patient comorbidities and performance status. Then, there is the consideration of prior therapies, including the number of lines of therapy, what prior therapies they have been exposed to, and what toxicities they have had from their prior therapies. Finally, I consider the social factors, which include whether the patient will need a caretaker or not during specific treatment stages and whether they have access to this support.

If we make the determination that BsAbs are appropriate and indicated, then we think through this again with the patient’s priorities and specific drug characteristics because the route of administration may be important. Within the BCMA drug class of BsAbs for relapsed/refractory MM, we have 3 different options: linvoseltamab is administered intravenously, whereas elranatamab and teclistamab are subcutaneous injections. If the patient has poor access, maybe IV is not a great option for them. Similarly, if they are tired of being stuck by an injection needle into their abdomen, maybe IV is a preferred option for them.

I also consider the toxicity profile of the individual BsAb, as there are small variabilities among these profiles. The dosing schedule is worth considering since there are differences among how they are dosed, the timing, and when the label allows you to space out to different dosing intervals. These are the types of things we take into consideration in our practice when we are selecting among BsAb products for our patients.

In your practice, what do you think are the most important factors to counsel a patient and caregiver about regarding the BsAb therapy?

Sara A. Scott, PharmD, BCOP:
A major counseling point is the management of cytokine release syndrome (CRS) and immune effector cell–associated neurotoxicity syndrome (ICANS), especially what the roles are for the patient and their caregiver. The incidence of grades 1 and 2 CRS was 46% with linvoseltamab, 58% with elranatamab, 72% with teclistamab, and 76% with talquetamab. Most of the CRS events were grade 1, and less than 1% of the events were grade 3 or higher. ICANS is uncommon with BsAbs, with incidences of 3% with teclistamab, 3% with elranatamab, 6% with talquetamab, and 8% with linvoseltamab, all of which were grade 1-4. 

Syeda Saba Kareem, PharmD, BCOP:
Patients and caregivers need to be aware of signs that may indicate CRS. Most CRS occurs during the first 2 step-up doses. By the time we get to the full treatment dose, the CRS rates are much lower. The symptoms include fever ≥100.4°F, rigors, joint pain, muscle pain, nausea, vomiting, anorexia, fatigue, headache, racing heart (>100 beats/minute resting), neurologic changes, shortness of breath, wheezing, or labored breathing without exertion. Management is dependent on the grade of CRS the patient is experiencing, as we manage the treatment based on grading criteria.

With all grades, if a patient is experiencing CRS, we hold the BsAb until resolution. For grade 1 CRS, the mainstay is supportive care and consideration of oral or IV dexamethasone. Among patients who have high-risk CRS, you can also consider tocilizumab. For grade 2 CRS, the management should be symptomatic or supportive care with IV fluids and oxygen supplementation. At this point, start steroids at every-12-hour dosing. For patients who have high-risk or prolonged CRS, you may also want to consider tocilizumab. If it is an IV infusion, then when we resume treatment with BsAbs after a patient has resolved CRS, we decrease the infusion rate by up to 50%. If a patient is experiencing grade 3 CRS, you want to consider ICU-level care. We increase the frequency of the steroids, give tocilizumab, and even consider other alternatives if needed. If a patient is experiencing grade 4 or more severe CRS, we increase the dose and frequency of steroids by giving high-dose methylprednisolone. We also give tocilizumab.

Another point is that if a patient experiences symptoms of CRS, you must evaluate for an infection, because a lot of these symptoms could be from an infection. If a patient is neutropenic, initiate empiric antibiotics. High-risk features where you would consider giving tocilizumab early would be higher tumor burden, rapid tumor progression, if they have high inflammatory markers like high CRP or ferritin, older age, and multiple comorbidities.

Then there are 3 main types of neurotoxicity associated with BsAb treatment: headaches, peripheral neuropathy, and ICANS. The way we assess ICANS is using the ICE score, which is the immune effector cell–associated encephalopathy score. Here, patients are asked a series of questions to look at their orientation to be able to name objects, follow commands, or write a sentence. Those are specifically asked of a patient every single time to assess their level of neurotoxicity. The grading for ICANS uses that ICE score, as well as other parameters like their level of consciousness, whether they have a seizure, any motor findings, or if they have elevated cerebral edema.

If a patient has grade 1 ICANS, the management or treatment is steroids, which can be increased to every 6 hours if it is unresolved. If a patient does experience ICANS regardless of any grade, we always want to consider seizure prophylaxis. If a patient is experiencing ICANS toxicity, you want to hold the BsAb. For grade 2 toxicity, you can also increase the steroids to every 6 hours. With grade 3, you again increase the steroids to a higher-grade, high-dose methylprednisolone (~1000 mg), which can go up to every 12 hours if it is refractory. Again, for grade 4, consider increasing methylprednisolone to 1000 mg every 12 hours.

We also need to consult with neurology, especially when a patient is refractory to dexamethasone. Neuroimaging is recommended for these patients if they have consistent or persistent ICANS toxicity. Aspiration precautions should be taken if a patient is admitted for ICANS toxicity; withholding oral intake, converting medications to IV, and doing a swallow evaluation are important. Then, the only time that we would ever consider tocilizumab is when a patient is having ICANS and concurrent CRS.

What strategies has your institution adopted to operationalize outpatient step-up dosing, and do you use any prophylaxis, whether that is dexamethasone post dose or tocilizumab pre dose?

Sara A. Scott, PharmD, BCOP:
We have a 100% outpatient program with the only exceptions being that patients without caregiver support require admission. These patients must be closely monitored. However, how that occurs varies depending on the institution. Some institutions perform nonstop remote monitoring (24/7), some prefer self-monitoring where patients check their own temperature and vital signs every 4-8 hours and report to the clinical team. The key element is to have frequent assessments, whether it occurs virtually or in person, in order to make sure the patient is tolerating therapy.

We were early adopters of prophylactic tocilizumab, and 1 of the questions I get from a lot of pharmacists is, “How do you manage the cost of that?” I would like to reassure everyone that we get reimbursed for every single dose. Tocilizumab is now integrated into the NCCN guidelines based on clinical trial data. I found out from our research team that we do have to appeal reimbursement often, which we do using a standard letter that includes not only the internal data that we have published, but also the NCCN guidelines. To date, we have not yet had a denial hold up.

We also prescribe pocket dexamethasone and Tylenol for outpatients on treatment. In addition, our patients are instructed to come in at any sign of CRS or ICANS. We handle most of them in the outpatient setting. We will admit people should they have grade 2 or persistent grade 1 toxicities, which is very rare.

Syeda Saba Kareem, PharmD, BCOP:
My institution does the same. We have adopted prophylactic tocilizumab. Nearly all patients with MM who are prescribed BsAbs receive these as outpatient service. We only admit them for social reasons. Another difference from your institution is that we admit patients for any grade CRS. Patients experiencing symptoms will come to the clinic for observation or admission if needed. The next phase is to prescribe pocket dexamethasone and have patients receive outpatient triage.

Sara A. Scott, PharmD, BCOP:
It is helpful with bed space, and I think that is what most institutions are finding. As we learn more about these therapies, the inpatient admission is probably not necessary for step-up dosing unless, as you said, they are having toxicity, and then of course, we need to take care of those patients.

Has your institution integrated primary prophylaxis with IVIG?

Syeda Saba Kareem, PharmD, BCOP:
Yes, we have. We created order sets and it is included in all our SOPs and guidelines to do primary prophylaxis for IVIG.

Sara A. Scott, PharmD, BCOP:
Most institutions are adopting primary prophylaxis with IVIG based on recent data. Ours is built into our BsAbs treatment plans. IVIG should be considered for the duration of treatment with BsAbs because it will significantly reduce the incidence of all-grade and severe infections.

Your Thoughts
What has been your BsAb antibody therapy? Do you have any specific questions for us? Please leave us your questions and comments below.

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Are you integrating the step-up dosing of BsAbs into treatment plans for patients with relapsed/refractory MM as an outpatient service?

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