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Nursing Challenges in Managing and Coordinating Care for Patients Experiencing Long-term Toxicities Related to CAR T-Cell Therapies

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Released: October 26, 2026

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In this commentary, experts discuss clinical evidence and practical considerations for optimizing nursing care of patients with relapsed/refractory multiple myeloma receiving bispecific antibody therapy. The commentary highlights efficacy findings from the MajesTEC-3 and MajesTEC-1 trials and examines the recognition and management of treatment-related adverse events, including CRS, ICANS, and infections. Strategies for infection prevention, including IVIG prophylaxis, and supportive care approaches for managing talquetamab-associated toxicities are addressed. The experts also emphasize patient and caregiver education, early symptom recognition, and coordination between academic and community oncology settings to support safe treatment administration, timely intervention, and preservation of patients' quality of life.

Charise Gleason
Charise Gleason, MSN, NP-C, AOCNP
Tiffany Richards
Tiffany Richards, PhD, ANP-BC, AOCNP
Nursing Challenges with CAR T

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Bispecific antibody therapies, including teclistamab, talquetamab, elranatamab and linvoseltamab, have transformed the treatment landscape for patients with relapsed/refractory (R/R) multiple myeloma (MM), offering remarkable responses even among heavily pretreated populations. In the phase III MajesTEC-3 trial, teclistamab plus daratumumab achieved a 36-month progression-free survival rate of 83.4%, compared to 29.7% with standard-of-care regimens. However, as these therapies move into earlier lines of treatment and increasingly into community oncology settings, nurses face new challenges in recognizing adverse events, preventing infections, supporting patients throughout treatment, and coordinating care across healthcare teams.

During recent educational programs, several important questions emerged regarding these challenges. Here, experts address key considerations to help nurses optimize outcomes while maintaining patients' quality of life.

How should nurses differentiate early treatment toxicities from longer-term complications?

Tiffany Richards PhD, ANP-BC, AOCNP: One of the most important points to emphasize when educating patients is that the timing of adverse events matters. With bispecific antibodies, cytokine release syndrome (CRS) typically occurs during step-up dosing or shortly after initial treatment doses. Most cases are grade 1 or 2, and fever is generally the first manifestation. Patients may also experience fatigue, myalgias, hypotension, or hypoxia.

Prophylactic tocilizumab can substantially reduce the incidence of CRS. In a cohort of patients from the phase I/II MajesTEC-1 study, prophylactic tocilizumab was associated with a reduction in CRS rates from approximately 72% in the pivotal study population to 25% in the prophylactic tocilizumab cohort, without an apparent reduction in treatment efficacy.

Neurotoxicity, including immune effector cell–associated neurotoxicity syndrome (ICANS), is less common with bispecific antibodies than with CAR T-cell therapy. Nevertheless, we need to educate caregivers to recognize confusion, changes in handwriting, difficulty following commands, or altered consciousness. The Immune Effector Cell-Associated Encephalopathy (ICE) assessment provides a standardized approach to evaluating cognitive function and contributes to ICANS grading alongside other neurologic findings. For example, if a patient receiving teclistamab presents with fever and fatigue during cycle 6, infection should be high on the differential diagnosis. This is why understanding the expected timing of toxicities is essential to effective nursing assessment.

What can nurses do to reduce the risk of serious infections?

Tiffany Richards PhD, ANP-BC, AOCNP: Infection prevention is probably one of the most important aspects of long-term management of patients being treated with bispecific antibodies. A key distinction is that a patient presenting with fever several months into bispecific antibody treatment should prompt immediate concern for infection rather than automatically being considered to have CRS.

Patients with MM already have impaired immune function because of their underlying disease and previous therapies. BCMA-directed bispecific antibodies further compromise humoral immunity by targeting normal plasma cells, contributing to profound hypogammaglobulinemia. Of importance, infection risk persists throughout treatment and may continue after therapy is discontinued.

Charise Gleason, MSN, NP-C, AOCNP: Compelling evidence supports intravenous immunoglobulin (IVIG) supplementation. In a retrospective study of 225 patients receiving BCMA-directed bispecific antibody therapy, primary IVIG prophylaxis was associated with longer median infection-free survival compared with no primary prophylaxis (7.7 vs 3 months).

Clinical practice has increasingly shifted toward proactive monthly IVIG supplementation during BCMA-directed bispecific antibody therapy, rather than waiting for patients to develop severe hypogammaglobulinemia or an infection. Earlier published consensus recommendations supported immunoglobulin replacement for patients with substantial immunoparesis, including IgG levels below 400 mg/dL or recurrent serious infections. More recent evidence and expert recommendations support a proactive approach to IVIG prophylaxis.

Other important preventive measures include antiviral prophylaxis, hepatitis B screening, appropriate Pneumocystis jirovecii pneumonia prophylaxis, vaccination, and monitoring for neutropenia. Also, remind patients that stopping treatment does not necessarily mean stopping infection prophylaxis. Immune recovery takes time, and we need to continue evaluating the need for supportive care.

How can we better manage the unique toxicities associated with talquetamab?

Tiffany Richards PhD, ANP-BC, AOCNP: Talquetamab is currently the only approved therapy targeting GPRC5D, which is expressed not only on myeloma cells but also in tissues involving the skin, nails, and oral cavity. Patients may experience dysgeusia, dry mouth, skin peeling, and nail changes. Of these, taste changes can be particularly challenging.

It is important to recognize how significantly the inability to taste food can affect nutritional intake, weight, and quality of life. Patients may become frustrated or begin avoiding foods they previously enjoyed. Nurses should prepare patients for these potential toxicities before treatment begins and provide practical recommendations, including saliva substitutes, adequate hydration, sugar-free lozenges, regular dental assessments, and dietary modifications based on individual taste changes. Involving dietitians early can be particularly beneficial. Skin moisturizers and supportive nail care may also help patients manage dermatologic toxicities.

For patients experiencing persistent or bothersome symptoms, treatment modifications, including reducing dosing frequency when clinically appropriate, may be considered with the treating team. One of the most reassuring messages to share is that these symptoms may improve over time. Setting realistic expectations can make a meaningful difference in treatment adherence.

How can nurses support safe transitions between academic and community oncology settings?

Charise Gleason, MSN, NP-C, AOCNP: As bispecific antibody therapy becomes more accessible, coordination between academic and community oncology centers is increasingly important. Historically, many patients underwent step-up dosing at academic centers before returning to their community oncologists for maintenance therapy. We are now seeing more centers establish outpatient administration programs, but careful patient selection remains essential.

Before initiating treatment, assess whether patients have reliable caregivers, transportation, access to emergency services, and the ability to monitor symptoms at home. One practical recommendation is to communicate with the community oncology team before treatment begins. Confirm that the prescribed bispecific antibody is available locally and that the center can provide necessary supportive treatments, including IVIG.

When transferring care, a direct handoff that clearly documents treatment schedules, adverse events during step-up dosing, infection prophylaxis, monitoring requirements, and emergency management plans is essential. Patients should not have to wonder whether their academic and community oncology teams are communicating. Nurses and nurse navigators are central to making these transitions successful.

How can we educate patients without increasing anxiety about treatment?

Tiffany Richards PhD, ANP-BC, AOCNP: One question on many minds is how to discuss CRS and ICANS without overwhelming patients. The key is to balance reassurance with clear, actionable instructions. It should be explained that most CRS events associated with bispecific antibodies are low grade and occur early in treatment, and the importance of promptly reporting fever or neurologic changes should be emphasized.

Rather than expecting patients to distinguish CRS from infection themselves, explicit instructions about when to contact the oncology team and when to seek emergency evaluation should be provided. Using plain language, written materials, and teach-back methods to confirm understanding is encouraged. Caregiver education is equally important because caregivers may recognize cognitive changes that patients do not identify themselves.

Ultimately, the goal is not simply to explain potential toxicities but to help patients feel prepared to recognize symptoms and respond appropriately.

Summary
Bispecific antibody therapies are creating meaningful opportunities for patients with R/R MM, but successful treatment extends beyond achieving a response. Nurses play an essential role in proactive toxicity monitoring, infection prevention, symptom management, and communication across healthcare settings.

By anticipating complications, individualizing supportive care, and empowering patients and caregivers with practical education, patients can remain on effective treatment while preserving their quality of life.

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What has been your greatest challenge when caring for patients receiving bispecific antibody therapy: managing infection risk, addressing persistent adverse events, educating patients and caregivers, or coordinating care between treatment centers? How have you adapted your nursing practice to address these challenges?

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When caring for patients with R/R MM receiving bispecific antibody therapy, which of the following presents the greatest challenge in your clinical practice?

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