Recommendations and considerations for assessments and interventions during the course of CAR-T
| 30 days prior to CAR-T . | Early post-CAR-T (≤30 days) . | Prolonged post-CAR-T (30-90 days) . | Late post-CAR-T (≥90 days) . |
|---|---|---|---|
| HBV | Bacterial prophylaxis | Pneumocystis jiroveciiprophylaxis | Vaccinations |
| Check HBsAg, HBcAb, or HBV DNA. If positive, 0.5 mg entecavir daily prior to LD, and continue for 12 months. Tenofovir is an acceptable alternative. | Levofloxacin 500 mg daily or equivalent with ANC <500/uL, until recovery (ANC >500/uL). | Start TMP-SMX daily, or equivalent, on day 30 for 6-12 months. Alternatives can include atovaquone, dapsone, or pentamidine. | Start COVID-19 and influenza vaccines at 3 months, other inactivated vaccines at 6 months, and live vaccines >1 year from CAR-T. |
| HCV/HIV | Fungal prophylaxis | IVIg | |
| Check HCV serology with reflex RNA and HIV fourth-generation antigen/antibody combination immunoassay. If positive consult with infectious disease for antiviral regimens. | Fluconazole 200 mg daily with ANC <500/uL until recovery (ANC >500/uL). If the patient has history of prior BMT, requires steroids for >3 days, or has prolonged neutropenia beyond 28 days, start a mold-active azolea with ANC <500/uL until recovery (ANC >500/uL). | If asymptomatic, assess IgG levels at day 30 and then every 3-6 months until consistently >400 mg/dL. If patient has recurrent sinopulmonary infections and IgG <400 mg/dL, give IVIg, 0.5 g/kg body weight, and reassess monthly for continued replacement need. | |
| HSV/VZV prophylaxis | Prolonged neutropenia | ||
| Start 800 mg acyclovir twice daily or 500 mg valacyclovir twice daily prior to LD, and continue for ≥6 months, or 6 months beyond last episode of HSV or VZV. | Consider G-CSF if ANC <500/µL beyond day 14. | ||
| Prolonged neutropenia | |||
| COVID/flu | |||
| Influenza and COVID-19 vaccination prior to apheresis. | |||
| CMV monitoring | |||
| Pursued in patients with prior BMT or BCMA-targeted CAR-T or those who receive steroids >3 days for 1 month post-cessation of immunosuppression. | |||
| 30 days prior to CAR-T . | Early post-CAR-T (≤30 days) . | Prolonged post-CAR-T (30-90 days) . | Late post-CAR-T (≥90 days) . |
|---|---|---|---|
| HBV | Bacterial prophylaxis | Pneumocystis jiroveciiprophylaxis | Vaccinations |
| Check HBsAg, HBcAb, or HBV DNA. If positive, 0.5 mg entecavir daily prior to LD, and continue for 12 months. Tenofovir is an acceptable alternative. | Levofloxacin 500 mg daily or equivalent with ANC <500/uL, until recovery (ANC >500/uL). | Start TMP-SMX daily, or equivalent, on day 30 for 6-12 months. Alternatives can include atovaquone, dapsone, or pentamidine. | Start COVID-19 and influenza vaccines at 3 months, other inactivated vaccines at 6 months, and live vaccines >1 year from CAR-T. |
| HCV/HIV | Fungal prophylaxis | IVIg | |
| Check HCV serology with reflex RNA and HIV fourth-generation antigen/antibody combination immunoassay. If positive consult with infectious disease for antiviral regimens. | Fluconazole 200 mg daily with ANC <500/uL until recovery (ANC >500/uL). If the patient has history of prior BMT, requires steroids for >3 days, or has prolonged neutropenia beyond 28 days, start a mold-active azolea with ANC <500/uL until recovery (ANC >500/uL). | If asymptomatic, assess IgG levels at day 30 and then every 3-6 months until consistently >400 mg/dL. If patient has recurrent sinopulmonary infections and IgG <400 mg/dL, give IVIg, 0.5 g/kg body weight, and reassess monthly for continued replacement need. | |
| HSV/VZV prophylaxis | Prolonged neutropenia | ||
| Start 800 mg acyclovir twice daily or 500 mg valacyclovir twice daily prior to LD, and continue for ≥6 months, or 6 months beyond last episode of HSV or VZV. | Consider G-CSF if ANC <500/µL beyond day 14. | ||
| Prolonged neutropenia | |||
| COVID/flu | |||
| Influenza and COVID-19 vaccination prior to apheresis. | |||
| CMV monitoring | |||
| Pursued in patients with prior BMT or BCMA-targeted CAR-T or those who receive steroids >3 days for 1 month post-cessation of immunosuppression. | |||
Mold-active azoles include voriconazole, posaconazole, or isavuconazole.
G-CSF, granulocyte colony-stimulating factor; TMP-SMX, trimethoprim-sulfamethoxazole.