Expanding Access to Bispecifics In R/R MM: Keys To Building Successful Outpatient Step-Up Dosing Models

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Institutional experience with outpatient bispecific administration demonstrates significant safety improvements through systematic protocol development. Analysis of initial inpatient experiences revealed predictable cytokine release syndrome patterns occurring within 48 hours of step-up dosing, leading to the implementation of preemptive tocilizumab administration. This approach reduced serious cytokine release syndrome rates from 70% to less than 20%, enabling safe transition to outpatient models.

The comprehensive outpatient program requires extensive infrastructure, including 24-hour physician coverage, educated nursing staff across all care areas, and systematic patient education protocols. Critical success factors include patient selection criteria (living within 30 minutes of the treatment center), detailed patient education on symptom recognition and temperature monitoring, and provision of take-home medications including dexamethasone for immediate symptom management. All patients receive preemptive tocilizumab, with documented reduction in readmission rates to 3% for high-grade toxicities.

Prophylactic medication strategies emphasize tocilizumab over dexamethasone for cytokine release syndrome prevention due to pharmacokinetic advantages—tocilizumab remains active for approximately 2 weeks whereas dexamethasone has a much shorter half-life. Understanding these pharmacologic differences allows for optimized dosing strategies that provide sustained protection during the highest-risk period. Insurance coverage for prophylactic tocilizumab is typically included in the initial bispecific approval, addressing common reimbursement concerns that might otherwise limit optimal patient care.