1. Better to do CAR-T before BCMA bispecific Ab: ORR in BCMA naive pt going for CAR-T --> 98% compared to less than 60% for those with prior exposure to teclistamab and elranatamab ( 2 BCMA bispecifics).
2. Frail patients can still get CAR-T even if ineligible for auto SCT
3. Highly proliferative R/R myeloma not a good candidate without bridging or debulking
4. Acute toxicity of BCMA CAR-T:
a. CRA 80%
b. HLH- high ferritin
c. Sarcoidosis like flare up
d. Infections
e. Cytopenias after CAR-T are biphasic. The initial one at the time of CAR-T infusion is due to lymphodepletion. The second nadir in a month is due to bone marrow inflammation and on target B and plasma cell destruction
f. Neurotoxicity in 20&. Parkinson like syndrome can be seen. Cytoxan may be useful to treat it.
