Cytokine Release Syndrome (CRS) Grading
ASTCT 2019 consensus grading of cytokine release syndrome (CRS) after CAR-T cells, bispecific antibodies or other immune effector cell therapies. Fever is required; the grade (1–4) is set by the more severe of hypotension and hypoxia. Guides management with tocilizumab and corticosteroids.
Score interpretation
ASTCT grading requires fever ≥ 38 °C (unless masked by treatment for CRS already given).
→ Look for another cause of hypotension or hypoxia; keep monitoring per the CAR-T protocol.
CRS Grade 1 — fever only
→ Monitoring and supportive care; antipyretics (paracetamol); IV fluids for fever; frequent observations; do NOT administer tocilizumab or steroids for Grade 1 alone; oncology/haematology team notification; continue CAR-T monitoring protocol
CRS grade 2 — fever with hypotension not needing vasopressors and/or hypoxia needing low-flow oxygen
→ Adults: tocilizumab 8 mg/kg IV (max 800 mg); IV fluids; supplemental O2; monitoring in IMCU or step-down setting; repeat dose if no improvement in 12–24h; consider corticosteroids if no response to 2nd tocilizumab dose; oncology MDT involvement. Children: use a children's formulary.
CRS grade 3 — fever with hypotension needing one vasopressor and/or hypoxia needing high-flow oxygen or a mask
→ ICU admission. Adults: tocilizumab 8 mg/kg IV immediately; high-dose corticosteroids (dexamethasone 10 mg q6h IV); vasopressor support; mechanical ventilation if required; anakinra if refractory; aggressive supportive care; frequent labs (ferritin, fibrinogen, LFTs); screen for HLH/MAS overlap; haematology + critical care MDT. Children: use a children's formulary.
CRS grade 4 — fever with hypotension needing multiple vasopressors and/or hypoxia needing positive pressure
→ ICU admission. Adults: tocilizumab 8 mg/kg IV immediately; high-dose corticosteroids (dexamethasone 10 mg q6h IV); vasopressor support; mechanical ventilation if required; anakinra if refractory; aggressive supportive care; frequent labs (ferritin, fibrinogen, LFTs); screen for HLH/MAS overlap; haematology + critical care MDT. Children: use a children's formulary.
Interpretation bands for the CRS Grading. Apply clinical judgement and local guidance.
References
- Lee DW et al. ASTCT Consensus Grading for Cytokine Release Syndrome and Neurologic Toxicity Associated with Immune Effector Cells. Biol Blood Marrow Transplant. 2019;25(4):625–638.
Related
Curated clinical cross-links plus same-class fallbacks.
- Tocilizumab (ICU — Cytokine Storm / COVID-19) · IL-6 Receptor Inhibitor
- Nebivolol · Cardioselective β1-blocker (with NO release)
- Grass pollen extracts · Allergen immunotherapy
- House dust mite extracts · Allergen immunotherapy
- Hydrocortisone (Oral Replacement) · Glucocorticoid Replacement
- Aciclovir 800mg Tablets (Ramsay Hunt Syndrome / Herpes Zoster Oticus) · Antiviral — nucleoside analogue (herpes zoster treatment)
- Cutaneous Lupus Erythematosus · BAD; EULAR
- Osteoporosis / Fragility Fracture · NOGG 2021; NICE NG147; NG224
- Arteritic AION (Giant Cell Arteritis) · RCOphth; BSR
- Osteoarthritis Hip / Knee Management · NICE NG226 (2022)
- Lupus Nephritis · EULAR/ERA-EDTA 2019; KDIGO 2024
- Rheumatoid Arthritis Management · NICE CG79 2018 / EULAR 2022
Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.