• Monitor for signs and symptoms of CRS (fever, hypoxia, chills, hypotension, sinus tachycardia, headache, elevated liver enzymes). Hold therapy and administer supportive therapy for CRS, may include intensive care for severe or life threatening CRS. Consider laboratory testing to monitor for disseminated intravascular coagulation (DIC), hematology parameters, as well as pulmonary, cardiac, renal, and hepatic function. Grade 1 CRS: If temperature ≥100.4°F (38°C), hold teclistamab until CRS resolves. Administer pretreatment medications prior to next dose of teclistamab. Grade 2 CRS: If temperature ≥100.4°F (38°C) with hypotension responsive to fluids and not requiring vasopressors, and/or, oxygen requirement of low-flow nasal cannula or blow-by, hold teclistamab until CRS resolves. Administer pretreatment medications prior to next dose. Hospitalize patients for 48 hrs following the next dose of teclistamab. Grade 3 CRS: If temperature ≥100.4°F (38°C) with hypotension requiring one vasopressor with or without vasopressin, and/or, oxygen requirement of high-flow nasal cannula, face mask, non-rebreather mask, or Venturi mask, First occurrence of Grade 3 CRS with duration <48 hrs, hold teclistamab until CRS resolves. Provide supportive therapy, which may include intensive care. Administer pretreatment medications prior to next dose. Hospitalize patients for 48 hrs following the next dose of teclistamab. For recurrent Grade 3 CRS or Grade 3 CRS with duration ≥48 hrs, permanently discontinue teclistamab. Provide supportive therapy, which may include intensive care. Grade 4: If temperature ≥100.4°F (38°C) with hypotension requiring multiple vasopressors (excluding vasopressin), and/or, oxygen requirement of positive pressure (continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), intubation, and mechanical ventilation), permanently discontinue teclistamab. Provide supportive therapy, which may include intensive care.
• At the first sign of neurologic toxicity, including ICANS, hold teclistamab and consider neurology evaluation. Rule out other causes of neurologic symptoms. Provide supportive therapy, which may include intensive care, for severe or life-threatening neurologic toxicities, including ICANS.Neurologic toxicity, excluding ICANS, Grade 1, hold teclistamab until neurologic toxicity symptoms resolve or stabilize. Grade 2 or first occurrence of Grade 3, hold teclistamab until neurologic toxicity symptoms improve to ≤Grade 1. Provide supportive therapy. Grade 3 (Recurrent) or Grade 4, permanently discontinue teclistamab. Provide supportive therapy, which may include intensive care. Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS)Grade 1, depressed level of consciousness: awakens spontaneously, hold teclistamab until ICANS resolves. Monitor neurologic symptoms and consider consultation with neurologist for further evaluation and management, including consideration for starting non-sedating, anti-seizure medicines for seizure prophylaxis. Grade 2, depressed level of consciousness: awakens to voice, hold teclistamab until ICANS resolves. Administer dexamethasone 10 mg IV every 6 hrs. Continue dexamethasone use until resolution to ≤Grade 1, then taper. Monitor neurologic symptoms and consider consultation with neurologist; consider starting non-sedating, anti-seizure medicines for seizure prophylaxis. Hospitalize patients for 48 hrs following the next dose of teclistamab. Grade 3, depressed level of consciousness: awakens only to tactile stimulus, or seizures, either: any clinical seizure, focal or generalized, that resolves rapidly, or non-convulsive seizures on electroencephalogram (EEG) that resolve with intervention, or raised intracranial pressure: focal/local edema on neuroimaging, Administer dexamethasone 10 mg IV every 6 hrs. Continue dexamethasone use until resolution to Grade 1 or less, then taper. Monitor neurologic symptoms and consider consultation with neurologist for further evaluation and management, including consideration for starting non-sedating, anti-seizure medicines for seizure prophylaxis. Provide supportive therapy, which may include intensive care. Hospitalize patients for 48 hrs following the next dose of teclistamab. Recurrent Grade 3 ICANS:discontinue teclistamab permanently. Administer dexamethasone 10 mg IV and repeat dose every 6 hrs. Continue dexamethasone until resolution to ≤ Grade 1, then taper. Monitor neurologic symptoms and consider consultation with neurologist for further evaluation and management, including consideration for starting non-sedating, anti-seizure medicines for seizure prophylaxis. Provide supportive therapy, which may include intensive care. Grade 4, depressed level of consciousness: either patient is unarousable or requires vigorous or repetitive tactile stimuli to arouse, OR stupor or coma, or seizures, either life-threatening prolonged seizure (>5 min), or repetitive clinical or electrical seizures without return to baseline in between, OR motor findings: deep focal motor weakness (hemiparesis or paraparesis), OR raised intracranial pressure/cerebral edema, with signs/symptoms such as diffuse cerebral edema on neuroimaging, decerebrate or decorticate posturing, cranial nerve VI palsy, papilledema, or Cushing’s triad, Permanently discontinue teclistamab. Administer dexamethasone 10 mg IV and repeat dose every 6 hrs. Continue dexamethasone until resolution to ≤Grade 1, then taper. Alternatively, consider administration of methylprednisolone 1,000 mg per day IV and continue methylprednisolone 1,000 mg per day IV for ≥2 days. Monitor neurologic symptoms and consider consultation with neurologist for further evaluation and management, including consideration for starting non-sedating, anti-seizure medicines for seizure prophylaxis. Provide supportive therapy, which may include intensive care.
• Monitor for signs and symptoms of infection. For all grades of infection, hold teclistamab in patients with active infection during the step-up dosing schedule. For Grade 3 infections, hold subsequent doses of until infection improves to ≤Grade 1. For Grade 4 infections, Consider permanent discontinuation of teclistamab. If not permanently discontinued, hold subsequent doses until infection improves to ≤Grade 1.

Lab Test Considerations:

• Verify negative pregnancy test before starting therapy.Monitor CBC at baseline and periodically during therapy and provide supportive care. Monitor patients with neutropenia for signs of infection. If ANC <0.5 x 10⁹/L, hold teclistamab until ANC ≥0.5 x 10⁹/L. If febrile neutropenia occurs,hold dose until ANC is ≥1 x 10⁹/L and fever resolves. If hemoglobin <8 g/dL, hold doses until hemoglobin is ≥8 g/dL. If platelet count <25,000/mcL or platelet count between 25,000/mcL and 50,000/mcL with bleeding,hold teclistamab until platelet count is ≥25,000/mcL and no evidence of bleeding.
  • Monitor liver enzymes and bilirubin at baseline and periodically during therapy. May cause elevated AST and ALT. Hold teclistamab or consider permanent discontinuation of therapy.