From the Research
Management of pembrolizumab-induced cytokine release syndrome (CRS) with rash, acute transverse myelitis, and inflammatory arthritis requires immediate discontinuation of pembrolizumab and initiation of high-dose corticosteroids, as supported by the most recent study 1. The treatment should start with methylprednisolone 1-2 mg/kg/day IV or equivalent, typically for 3-5 days, followed by oral prednisone 1 mg/kg/day with a gradual taper over 4-6 weeks based on clinical response. Some key points to consider in the management of CRS include:
- For severe or steroid-refractory cases, consider adding tocilizumab (8 mg/kg IV, maximum 800 mg) as it specifically blocks IL-6, a key cytokine in CRS pathophysiology, as seen in a case report 1.
- The neurologic manifestation of transverse myelitis requires urgent neurological consultation and may necessitate more aggressive immunosuppression, potentially including plasma exchange or intravenous immunoglobulin (IVIG 2 g/kg divided over 2-5 days), as reported in a study on longitudinal extensive transverse myelitis 2.
- Supportive care is essential, including antipyretics, IV fluids, and close monitoring of vital signs and organ function.
- The inflammatory arthritis component may require additional NSAIDs or disease-modifying antirheumatic drugs if persistent after steroid treatment, as noted in a case of pembrolizumab-induced inflammatory arthritis 3. This comprehensive approach targets the underlying immune hyperactivation causing these immune-related adverse events, as pembrolizumab's blockade of PD-1 can lead to dysregulated T-cell activation and inflammatory cytokine release affecting multiple organ systems, as highlighted in a case report of CRS induced by pembrolizumab 4.