[Modern immunotherapy and emergency situations : Toxicities of CAR T-cell therapies and BiTEs, their management, and their relevance in intensive care medicine].

Abstract

Novel immunotherapies such as chimeric antigen receptor T‑cell therapy (CAR T‑cell therapy) and bispecific T‑cell engagers (BiTEs) have transformed the treatment of hematologic malignancies in recent years. Despite their high efficacy, they pose considerable risks, particularly for cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Both typically occur within the first 2 weeks after therapy and may require admission to an intensive care unit (ICU). Other relevant side effects include persistent cytopenias, hypogammaglobulinemia, and increased susceptibility to infections. These long-term complications are gaining importance and require structured follow-up strategies. Up to 35% of patients undergoing CAR T‑cell therapy require intensive care, mostly due to CRS or ICANS. Nevertheless, the rates of organ support and ICU mortality remain comparatively low, indicating that these toxicities are, in principle, manageable. The severe toxicities of these novel therapies increasingly pose ethical challenges in intensive care. Decision-making frameworks such as the "ICU trial" model can provide valuable guidance. This article offers a comprehensive overview of acute and delayed side effects of immune-based therapies, their intensive care management, and current strategies for optimizing patient care.