Step-up dosing (T-cell engagers)
Starting a powerful immune drug at a tiny dose and increasing it over several days, so the immune system is switched on gradually and the dangerous fever-and-low-blood-pressure reaction (cytokine release) stays mild.
Bispecific T-cell engagers (teclistamab, glofitamab, epcoritamab, tarlatamab) are given in step-up doses over the first week, often with steroid or tocilizumab premedication and inpatient monitoring, after which CRS risk falls sharply and dosing can continue in clinic. The requirement for hospital beds during step-up has slowed community adoption and motivates subcutaneous formulations, prophylactic tocilizumab and outpatient protocols. Venetoclax uses a similar five-week ramp-up in CLL to prevent tumour lysis syndrome.
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