Step-up Dosing with Bispecifics

Step-up Dosing with Bispecifics

Implementation of outpatient step-up dosing for bispecific antibodies requires significant institutional infrastructure development. Many centers initially performed inpatient dosing but are transitioning to outpatient approaches using existing resources from COVID-era monitoring systems or outpatient CAR-T and autologous transplant programs. Establishing 24/7 monitoring capabilities and integrating multiple institutional departments (clinical, pharmacy, administrative) represents a major implementation challenge.

Prophylactic tocilizumab substantially reduces cytokine release syndrome incidence from approximately 70% to 20%, enabling safer outpatient administration. Patients receive tocilizumab prophylaxis, emergency contact information for intermediate care centers, pocket dexamethasone, and clear instructions to return if symptoms develop. Approximately 75% of patients can receive outpatient step-up dosing, with the remaining 25% requiring inpatient administration due to high disease burden, lack of adequate caregiver support, or other safety concerns.

Access to dedicated 24-hour intermediate care units specifically for oncology patients facilitates rapid evaluation and management of any complications arising from outpatient bispecific administration. The infrastructure developed for outpatient bispecific dosing can subsequently support expansion of outpatient CAR-T and autologous transplant programs, representing a broader institutional capability enhancement beyond bispecifics alone.