# Cytokine release syndrome after CAR T-cell therapy: ASTCT grading, tocilizumab and steroids

Source: https://onco.cc/protocols/crs-grading-and-management/  
OnCo record `crs-grading-and-management` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

After CAR T-cell therapy, the immune cells can release a flood of chemical messengers, causing fever, low blood pressure and breathing trouble: cytokine release syndrome. Any fever after CAR T-cell therapy needs the treating centre at once. Teams grade it from 1 to 4 and treat with tocilizumab and, if needed, steroids; infection is treated at the same time because the two look alike.

## Summary

CRS usually starts within 1 to 2 weeks of infusion (median 2 to 3 days for tisagenlecleucel and axicabtagene ciloleucel, sometimes within 24 hours) (SITC 2020). ASTCT 2019 grading: fever of 38 °C or more not attributable to another cause, with grade set by the worse of hypotension (grade 2 no vasopressor, grade 3 one vasopressor with or without vasopressin, grade 4 several) and hypoxia (grade 2 low-flow oxygen up to 6 L/min, grade 3 high-flow, face mask or non-rebreather, grade 4 positive pressure). Once antipyretics, tocilizumab or steroids are given, fever is no longer needed to grade.

SITC 2020: tocilizumab may be considered at grade 2 in adults (LE: 3) and earlier for older or comorbid patients; in children, at grade 3 (LE: 3). If one dose does not work, give steroids with a second dose (LE: 3); after two doses, consider anakinra, siltuximab or high-dose methylprednisolone (LE: 4). EBMT/JACIE 2019 limits tocilizumab to four doses per episode and names siltuximab as second line. Presume infection and treat it while investigating; neutropenic fever antibiotics are not delayed for a presumed CRS. Daily blood count, metabolic panel, magnesium, phosphate, CRP and ferritin while in hospital; cardiac assessment for prolonged severe CRS; hold G-CSF and avoid GM-CSF during CRS.

The ASTCT 2026 update to the grading and the 2022 EBMT/JACIE/EHA recommendations were read only as abstracts.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: CRS management; cytokine release syndrome grading; ASTCT CRS grading; tocilizumab for CRS; CAR-T fever
- Tags: protocol; cell-therapy; car-t; acute-oncology

## Connected records

- protocols: [ICANS after CAR T-cell therapy: ICE score, ASTCT grading, steroids and seizure management](https://onco.cc/protocols/icans-grading-and-management/), [IEC-HS after CAR T-cell therapy: recognition and stepwise treatment](https://onco.cc/protocols/iec-hs-management/), [Infection screening, prophylaxis and immunoglobulin replacement around CAR T-cell therapy](https://onco.cc/protocols/car-t-infection-prevention/), [Prolonged low blood counts after CAR T-cell therapy (ICAHT): grading, work-up and treatment](https://onco.cc/protocols/icaht-prolonged-cytopenia/), [Suspected febrile neutropenia (neutropenic sepsis): the first hour](https://onco.cc/protocols/febrile-neutropenia-first-hour/), [T-cell engaging bispecific antibodies: step-up dosing, monitoring and outpatient delivery](https://onco.cc/protocols/bispecific-step-up-dosing/)
- technologies: [CAR-T cell therapy](https://onco.cc/technologies/car-t/)
- drugs: [Axicabtagene ciloleucel](https://onco.cc/drugs/axicabtagene-ciloleucel/), [Brexucabtagene autoleucel](https://onco.cc/drugs/brexucabtagene-autoleucel/), [Ciltacabtagene autoleucel](https://onco.cc/drugs/ciltacabtagene-autoleucel/), [Dexamethasone](https://onco.cc/drugs/dexamethasone/), [Idecabtagene vicleucel](https://onco.cc/drugs/idecabtagene-vicleucel/), [Lisocabtagene maraleucel](https://onco.cc/drugs/lisocabtagene-maraleucel/), [Methylprednisolone](https://onco.cc/drugs/methylprednisolone/), [Obecabtagene autoleucel](https://onco.cc/drugs/obecabtagene-autoleucel/), [Siltuximab](https://onco.cc/drugs/siltuximab/), [Tisagenlecleucel](https://onco.cc/drugs/tisagenlecleucel/), [Tocilizumab](https://onco.cc/drugs/tocilizumab/)
- institutions: [Society for Immunotherapy of Cancer](https://onco.cc/institutions/sitc/)
- terms: [Cytokine release syndrome (CRS)](https://onco.cc/terms/crs/), [Cytokine release syndrome and ICANS: grading and management](https://onco.cc/terms/lymphoma-tx-crs-icans/)

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