• Monitor for signs and symptoms of CRS (fever, hypoxia, chills, hypotension, sinus tachycardia, headache, ↑ 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 and hematology parameters, as well as pulmonary, cardiac, renal, and hepatic function. Grade 1 CRS: If temperature ≥100.4°F, hold teclistamab until CRS resolves. Administer pretreatment medications prior to next dose of teclistamab. Grade 2 CRS: If temperature ≥100.4°F 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 hr following the next dose of teclistamab. Grade 3 CRS: If temperature ≥100.4°F with hypotension requiring one vasopressor with or without vasopressin and/or oxygen requirement of high-flow nasal cannula (>6 L/min), face mask, nonrebreather mask, or Venturi mask, 1st occurrence of Grade 3 CRS with duration <48 hr, hold teclistamab until CRS resolves. Provide supportive therapy, which may include intensive care. Administer pretreatment medications prior to next dose. Hospitalize patients for 48 hr following the next dose of teclistamab. For recurrent Grade 3 CRS or Grade 3 CRS with duration ≥48 hr, permanently discontinue teclistamab. Provide supportive therapy, which may include intensive care. Grade 4 CRS: If temperature ≥100.4°F with hypotension requiring multiple vasopressors (excluding vasopressin) and/or oxygen requirement of positive pressure (continuous positive airway pressure, bilevel positive airway pressure, 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 1st 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. 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 nonsedating antiseizure 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 hr. Continue dexamethasone until resolution to ≤Grade 1; then taper. Monitor neurologic symptoms and consider consultation with neurologist; consider starting nonsedating antiseizure medicines for seizure prophylaxis. Hospitalize patients for 48 hr 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 nonconvulsive seizures on electroencephalogram that resolve with intervention, or raised intracranial pressure: focal/local edema on neuroimaging): Administer dexamethasone 10 mg IV every 6 hr. Continue dexamethasone use until resolution to ≤Grade 1; then taper. Monitor neurologic symptoms and consider consultation with neurologist for further evaluation and management, including consideration for starting nonsedating antiseizure medicines for seizure prophylaxis. Provide supportive therapy, which may include intensive care. Hospitalize patients for 48 hr following the next dose of teclistamab. Recurrent Grade 3 ICANS: Discontinue teclistamab permanently. Administer dexamethasone 10 mg IV and repeat dose every 6 hr. 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 nonsedating antiseizure 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 ↑ 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 hr. Continue dexamethasone until resolution to ≤Grade 1; then taper. Alternatively, consider administration of methylprednisolone 1000 mg per day IV and continue methylprednisolone 1000 mg per day IV for ≥2 days. Monitor neurologic symptoms and consider consultation with neurologist for further evaluation and management, including consideration for starting nonsedating antiseizure 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 × 10⁹/L, hold teclistamab until ANC ≥0.5 × 10⁹/L. If febrile neutropenia occurs, hold teclistamab until ANC ≥1 × 10⁹/L and fever resolves. If hemoglobin <8 g/dL, hold teclistamab until hemoglobin ≥8 g/dL. If platelet count <25,000/mcL or platelet count 25,000–50,000/mcL with bleeding, hold teclistamab until platelet count ≥25,000/mcL and no evidence of bleeding.
  • Monitor liver enzymes and bilirubin at baseline and periodically during therapy. May cause ↑ AST and ALT. Hold teclistamab or consider permanent discontinuation of therapy.