Monitoring, Educating Patients on Tarlatamab of ICANS and CRS Risk

Tarlatamab-dlle (Imdelltra), like other T-cell engaging therapies, carries a risk of cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS).¹ In the retrospective analysis that Laura Alder, MD, presented at the 2026 SNO/ASCO CNS Metastases Conference, CRS occurred in over half of patients, with ICANS rates that varied depending on how recently patients had received CNS radiation before starting treatment. These risks raised practical questions not just for academic centers, but for community oncology practices that may have more limited resources for monitoring patients through the early treatment window when these toxicities are most likely to emerge.

In an interview with CancerNetwork®, Alder, assistant professor of medicine at Duke University School of Medicine, discussed the concrete steps her team takes to monitor and educate patients with known brain metastases who are starting tarlatamab. Alder emphasized the importance of detailed, upfront conversations with both patients and their caregivers, so they understand what symptoms to watch for, as a supportive caregiver system is essential for patients on this therapy. She also described specific tools her team has implemented, including wallet cards that allow patients to communicate their treatment regimen to providers if they go to an emergency room, and a “pill in the pocket” approach that sends patients home with dexamethasone so they can begin treating early symptoms en route to the hospital.

Alder tied these practical measures to a broader point about education for community providers and families and noted that as understanding of tarlatamab’s toxicity profile matures, clinicians may increasingly be able to risk-stratify patients to determine who requires inpatient monitoring vs who can be safely managed outpatient with close follow-up.

Transcript:

CancerNetwork: For a community oncologist with more limited resources than someone at an academic institution might have, what’s important to know about monitoring patients with known brain metastases who are going to be receiving tarlatamab?

Alder: A few things. Making sure that we’re having detailed conversations with a patient and a patient’s caregiver and supportive system, so they understand these risks and what to look out for. Tarlatamab is one of those medications where having a supportive care system and a caregiver is essential. Then the other thing is good education. At Duke, we give wallet cards, so the patient always has that with them. If they do go to the [emergency department], the local providers can know, “Hey, what drug are they on, what are we looking for, what’s the treatment.” Sometimes we send them home with dexamethasone, like a “pill-in-the-pocket”. If they do start having any of these symptoms, they can take the steroid—the dexamethasone—on the way to the hospital. Then just education for our community providers, and education for the patients and their families, is key. The more that we’re learning about tarlatamab, the more we’re beginning to risk-stratify these patients a bit. That could help us decide who needs to be inpatient vs who could be outpatient with close monitoring, and how we can best support the patient with where they are and what resources they have.

Reference

Alder L, Hess DL, Green AL, et al. Intracranial efficacy and treatment beyond CNS progression with tarlatamab in small cell lung cancer: a multi-institutional real-world analysis. Presented at the 2026 SNO ASCO CNS Metastases Conference; August 13-15, 2026; Boston, MA.