Note: Individualize dosage and frequency based on the severity of the disease and the initial response of the patient. Sudden withdrawal may lead to adrenal insufficiency or recurrent symptoms; tapering the dose and increasing the injection interval prior to discontinuation may be necessary following prolonged administration.
Usual dosage range :
IM, SUBQ: 40 to 80 units every 24 to 72 hours.
Indication-specific dosing:
Multiple sclerosis, acute exacerbations (alternative therapy): IM, SUBQ: 80 to 120 units/day for 2 to 3 weeks. Treatment guidelines recommend the use of high dose IV or oral methylprednisolone for acute exacerbations of multiple sclerosis (AAN [Scott 2011]; NICE 2014). Corticotropin may be an alternative therapy if IV corticosteroids cannot be administered or are not tolerated (Simsarian 2011).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in manufacturer's labeling; use with caution.
There are no dosage adjustments provided in manufacturer's labeling; use with caution in cirrhosis.
(For additional information see "Corticotropin injection gel: Pediatric drug information")
Note: Sudden withdrawal may lead to adrenal insufficiency or recurrent symptoms; tapering the dose prior to discontinuation of therapy may be necessary following prolonged administration.
Infantile spasms:
Note: Expert consensus guidelines based on currently available evidence show that corticotropin (ACTH) appears to be more effective than oral corticosteroids or vigabatrin (monotherapy) for the treatment of infantile spasms in most patients and is used most frequently for initial management of infantile spasms. For patients with tuberous sclerosis complex, corticotropin may be used for non-responders to vigabatrin therapy (AAN [Go 2012]; ILAE [Wilmshurst 2015]; Knupp 2016).
Although various dosing regimens (primarily high-dose and moderate/low-dose) have been described in the literature, an optimal dosing regimen has not been defined (AAN [Go 2012]; Hancock 2013; Pellock 2010; Mackay 2004). With the high-dose regimen, initial efficacy response rates of 86% to 93% during the respective study periods have been reported (Baram 1996; Snead 1989); however, a randomized, comparative trial did not show the high-dose superior to low-dose ACTH; however, hypertension occurred more frequently in the high-dose group (Hrachovy 1994). Guidelines suggest consideration for low-dose ACTH regimens (as an alternative to high-dose); however, literature also suggests that the two dosing regimens are probably equally effective for short-term treatment (AAN [Go 2012]). A US consensus report recommends short duration of high-dose (~2 weeks), followed by a taper (Pellock 2010). In clinical practice, high-dose ACTH is used more often by neurologists than low-dose protocols (Mytinger 2012). In the US market, Acthar gel has FDA approval for treatment of infantile spasm in patients <2 years of age; however, trials may have been conducted with other corticotropin repository gel products in other countries.
Infants and Children <2 years:
High dose: Body-surface area (BSA) directed dosing: IM: 75 units/m2/dose twice daily or 150 units/m2/dose once daily for 2 weeks, followed by a 2-week taper: 30 units/m2/dose once daily in the morning for 3 days, followed by 15 units/m2/dose once daily in the morning for 3 days, followed by 10 units/m2/dose once daily in the morning for 3 days and 10 units/m2/dose every other morning for 6 days (Hodgeman 2016; Acthar manufacturer's labeling). In practice, some centers have used maximum doses of 80 units/dose twice daily or 160 units/dose once daily based on currently available dosage forms.
Low dose: Fixed dosing: IM: Initial: 20 units/day for 2 weeks; if patient responds, taper and discontinue over a 1-week period; if patient does not respond, increase dose to 30 units/day for 4 weeks then taper and discontinue over a 1-week period. Dosing based on a prospective, single-blind study which reported no major difference in effectiveness between high-dose long-duration versus low-dose short-duration ACTH therapy (Hrachovy 1994).
Anti-inflammatory/immunosuppression:
Note: Although FDA approved, use has been replaced by other agents; most expert guidelines do not address corticotropin as a therapeutic option (ACR [Ringold 2013]; CAARA [Huber 2010]; KDIGO 2012):
Children >2 years and Adolescents:
Fixed dosing: Acthar: IM, SUBQ: 40 to 80 units/dose every 24 to 72 hours (manufacturer's labeling).
Weight-directed dosing: IM: 0.8 units/kg/day or 25 units/m2/day divided every 12 to 24 hours (Gal 2007).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in manufacturer's labeling; use with caution.
There are no dosage adjustments provided in manufacturer's labeling; use with caution in cirrhosis.
Refer to adult dosing.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Gel, Injection:
Acthar: 80 units/mL (5 mL) [contains phenol]
Cortrophin: 80 units/mL (5 mL) [contains phenol]
No
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution Reconstituted, Injection:
ACTH 40: 40 units ([DSC])
Purified Cortrophin Gel: FDA approved November 2021; availability anticipated in the first quarter of 2022. Information pertaining to this product within the monograph is pending revision. Purified Cortrophin Gel is indicated for the treatment of certain chronic autoimmune disorders, including acute exacerbations of multiple sclerosis and rheumatoid arthritis, in addition to excess urinary protein due to nephrotic syndrome. Consult the prescribing information for additional information.
Acthar Gel is only available through specialty pharmacy distribution and not through traditional distribution sources (eg, wholesalers, retail pharmacies). Hospitals wishing to acquire Acthar Gel should contact CuraScript Specialty Distribution (1-877-599-7748).
After treatment is initiated, discharge or outpatient prescriptions should be submitted to the Acthar Support and Access Program (A.S.A.P.) in order to ensure an uninterrupted supply of the medication. The Acthar Referral/Prescription form is available online at http://www.acthar.com/files/Acthar-Prescription-Referral-Form.pdf.
Additional information is available for the A.S.A.P. at http://www.acthar.com/healthcare-professionals/physician-patient-referrals or by calling 1-888-435-2284.
An FDA-approved patient medication guide, which is available with the product information and at https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/008372s068lbl.pdf#page=18, must be dispensed with this medication.
IM, SUBQ: For IM or SUBQ use; do not administer IV. Warm gel to room temperature before administration. Do not over-pressurize vial prior to withdrawing product.
Parenteral: Warm gel before administration; do not over-pressurize vial when withdrawing product. May be administered IM or SubQ; IM route is recommended for the treatment of infantile spasms; do not administer IV.
Diuresis in nephrotic syndrome: To induce a diuresis or remission of proteinuria in patients with nephrotic syndrome without uremia of the idiopathic type or due to lupus erythematosus. Note: Based on the 2012 KDIGO clinical practice guidelines for glomerulonephritis, recommendations cannot be made for the use of corticotropin for initial therapy or relapses of idiopathic membranous nephropathy until more randomized, controlled trials are conducted. The KDIGO guidelines do not include recommendations for use of corticotropin in the treatment of proteinuria due to lupus nephritis (KDIGO 2012).
Infantile spasms (Acthar gel): Treatment of infantile spasms in infants and children younger than 2 years. Note: Corticotropin is the preferred treatment in most patients (AAN [Go 2012])
Multiple sclerosis: Treatment of acute exacerbations of multiple sclerosis in adults. Note: Treatment guidelines recommend the use of high dose IV or oral methylprednisolone for acute exacerbations of multiple sclerosis (AAN [Scott 2011]; NICE 2014). Corticotropin may be an alternative therapy if IV corticosteroids cannot be administered or are not tolerated (Simsarian 2011).
Ophthalmic diseases: Treatment of severe acute and chronic allergic and inflammatory processes involving the eye and its adnexa (eg, allergic conjunctivitis, keratitis, iritis, iridocyclitis, diffuse posterior uveitis, choroiditis, optic neuritis, chorioretinitis, anterior segment inflammation). Note: FDA approved use; however, available data to support use in these conditions is limited.
Symptomatic sarcoidosis: Treatment of symptomatic sarcoidosis. Note: FDA approved use; however, available data to support use in this condition is limited. Glucocorticoids (eg, prednisone) are generally recommended as first-line treatment for sarcoidosis (Soto-Gomez 2016).
Corticotropin may be confused with corticorelin, cosyntropin
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Reported adverse reactions are for infants and children for infantile spasms unless otherwise noted. Other adverse events associated with corticosteroids may also occur.
>10%:
Cardiovascular: Hypertension (11%)
Infection: Infection (20%)
Nervous system: Seizure (12%)
1% to 10%:
Cardiovascular: Cardiac abnormality (cardiac hypertrophy: 3%)
Endocrine & metabolic: Drug-induced Cushing's syndrome (3%), weight gain (1%)
Gastrointestinal: Decreased appetite (3%), diarrhea (3%), vomiting (3%)
Infection: Candidiasis (≥2%)
Nervous system: Irritability (7%)
Otic: Otitis media (≥2%)
Respiratory: Nasal congestion (1%), pneumonia (≥2%), upper respiratory tract infection (≥2%)
Miscellaneous: Fever (5%)
Frequency not defined (all indications and populations):
Dermatologic: Acne vulgaris, ecchymoses, hyperpigmentation, inadvertent suppression of skin test reaction
Endocrine & metabolic: Decreased serum calcium, decreased serum potassium, growth retardation, impaired glucose tolerance/prediabetes, negative nitrogen balance, pituitary insufficiency, secondary adrenocortical insufficiency, sodium retention
Gastrointestinal: Acute peptic ulcer with hemorrhage and perforation
Hematologic & oncologic: Petechia
Immunologic: Antibody development
Nervous system: Idiopathic intracranial hypertension
Neuromuscular & skeletal: Amyotrophy, aseptic necrosis of femoral head, aseptic necrosis of humeral head, osteoporosis, pathological fracture (long bones), steroid myopathy
Ophthalmic: Exophthalmos, glaucoma, increased intraocular pressure, subcapsular posterior cataract
Miscellaneous: Wound healing impairment
Postmarketing (all indications and populations):
Cardiovascular: Atrial fibrillation, heart failure, necrotizing angiitis, palpitations, shock, subdural hematoma
Dermatologic: Diaphoresis, epidermal thinning, facial erythema
Endocrine & metabolic: Fluid retention (including peripheral swelling), hirsutism, hypokalemic alkalosis, increased serum glucose, menstrual disease
Gastrointestinal: Abdominal distention, impaired intestinal carbohydrate absorption, nausea, pancreatitis, ulcerative esophagitis
Hypersensitivity: Anaphylactic shock, anaphylaxis, hypersensitivity reaction
Infection: Abscess
Local: Injection site reaction
Nervous stem: Dizziness, fatigue, headache, insomnia, intracranial hemorrhage, lethargy, malaise, myasthenia, reversible cerebral atrophy (usually secondary to hypertension), vertigo
Neuromuscular & skeletal: Asthenia, vertebral compression fracture
Hypersensitivity to proteins of porcine origin; patients with scleroderma, osteoporosis, systemic fungal infections, ocular herpes simplex, peptic ulcer, recent surgery, congestive heart failure, uncontrolled hypertension, primary adrenocortical insufficiency, adrenocortical hyperfunction; IV administration.
Acthar gel: Additional contraindications: Children <2 years of age with suspected congenital infections; coadministration of live or live attenuated vaccines.
Concerns related to adverse effects:
• Adrenal suppression: May cause hypercortisolism or suppression of hypothalamic-pituitary-adrenal (HPA) axis, particularly in younger children or in patients receiving high doses for prolonged periods. HPA axis suppression may lead to adrenal crisis. Withdrawal and discontinuation of a corticosteroid should be done slowly and carefully. Symptoms of adrenal insufficiency may be difficult to detect in infants treated for infantile spasms.
• Electrolyte disturbances: May increase retention of sodium and wasting of calcium and potassium; sodium restriction and/or potassium supplementation may be required.
• Hypersensitivity reactions: Antibodies may develop following prolonged use and increase the risk of hypersensitivity reactions.
• Immunosuppression: Prolonged use of corticosteroids may increase the incidence of secondary infection, mask acute infection (including fungal infections), prolong or exacerbate viral infections, or limit response to vaccines. Close observation is required in patients with latent tuberculosis (TB) and/or TB reactivity; if therapy is prolonged, prophylaxis should be started.
• Psychiatric disturbances: Corticosteroids may cause psychiatric disturbances, including depression, euphoria, insomnia, irritability (especially in infants), mood swings, personality changes, and psychotic manifestations; effects are reversible upon discontinuation of therapy. Preexisting psychiatric conditions (eg, emotional instability, psychotic tendencies) may be exacerbated by corticosteroid use.
Disease-related concerns:
• Cardiovascular disease: Use with caution in patients with hypertension; use has been associated with fluid retention and hypertension; use is contraindicated with uncontrolled hypertension or congestive heart failure.
• Diabetes: Use with caution in patients with diabetes mellitus; may alter glucose production/regulation leading to hyperglycemia.
• Gastrointestinal disease: Use with caution in patients with GI disease (diverticulitis, ulcerative colitis, risk of impending perforation, fresh intestinal anastomoses) or abscess/pyogenic infections due to risk of gastric ulcer, GI perforation, and GI bleeding; use is contraindicated with peptic ulcer disease.
• Hepatic impairment: Use with caution in patients with hepatic impairment, including cirrhosis; long-term use has been associated with fluid retention.
• Myasthenia gravis: Use with caution in patients with myasthenia gravis; exacerbation of symptoms has occurred, especially during initial treatment with corticosteroids.
• Ocular disease: Use with caution in patients with cataracts and/or glaucoma; increased intraocular pressure, open-angle glaucoma, and cataracts have occurred with prolonged corticosteroid use. Consider routine eye exams in chronic users. Contraindicated in patients with ocular herpes simplex.
• Osteoporosis: Use with caution in patients of any age at risk for osteoporosis; high doses and/or long-term use of corticosteroids have been associated with increased bone loss and osteoporotic fractures. Use is contraindicated in patients with osteoporosis.
• Renal impairment: Use with caution in patients with renal impairment; fluid retention may occur.
• Thyroid disease: Changes in thyroid status may necessitate dosage adjustments; metabolic clearance of corticosteroids increases in hyperthyroid patients and decreases in hypothyroid ones.
Special populations:
• Pediatric: May affect growth velocity; growth should be routinely monitored in pediatric patients.
Concurrent drug therapy issues:
• Vaccines: For Acthar gel, concomitant use of live or live attenuated vaccines is contraindicated; use caution with inactivated vaccines (response may be variable). For Purified Cortrophin gel, avoid vaccination against smallpox; use caution with other immunization procedures.
Other warnings/precautions:
• Discontinuation of therapy: Withdraw therapy with gradual tapering of dose.
Use with caution in patients with osteoporosis; underlying clinical condition may also impact bone health and osteoporotic effect of corticosteroids and corticotropin in pediatric patients (Leonard 2007). Corticosteroid use may cause psychiatric disturbances, including depression, euphoria, insomnia, mood swings, personality changes, and irritability (especially in infants).
None known.
Abrocitinib: Corticosteroids (Systemic) may enhance the immunosuppressive effect of Abrocitinib. Management: The use of abrocitinib in combination with other immunosuppressants is not recommended. Doses equivalent to more than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks are considered immunosuppressive. Risk D: Consider therapy modification
Acetylcholinesterase Inhibitors: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Acetylcholinesterase Inhibitors. Increased muscular weakness may occur. Risk C: Monitor therapy
Amphotericin B: Corticosteroids (Systemic) may enhance the hypokalemic effect of Amphotericin B. Risk C: Monitor therapy
Androgens: Corticosteroids (Systemic) may enhance the fluid-retaining effect of Androgens. Risk C: Monitor therapy
Antidiabetic Agents: Hyperglycemia-Associated Agents may diminish the therapeutic effect of Antidiabetic Agents. Risk C: Monitor therapy
Aprepitant: May increase the serum concentration of Corticosteroids (Systemic). Management: No dose adjustment is needed for single 40 mg aprepitant doses. For other regimens, reduce oral dexamethasone or methylprednisolone doses by 50%, and IV methylprednisolone doses by 25%. Antiemetic regimens containing dexamethasone reflect this adjustment. Risk D: Consider therapy modification
Axicabtagene Ciloleucel: Corticosteroids (Systemic) may diminish the therapeutic effect of Axicabtagene Ciloleucel. Management: Avoid use of corticosteroids as premedication before axicabtagene ciloleucel. Corticosteroids may, however, be required for treatment of cytokine release syndrome or neurologic toxicity. Risk D: Consider therapy modification
Baricitinib: Corticosteroids (Systemic) may enhance the immunosuppressive effect of Baricitinib. Management: The use of baricitinib in combination with potent immunosuppressants is not recommended. Doses equivalent to more than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks are considered immunosuppressive. Risk D: Consider therapy modification
BCG Products: Corticosteroids (Systemic) may enhance the adverse/toxic effect of BCG Products. Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may diminish the therapeutic effect of BCG Products. Risk X: Avoid combination
Brincidofovir: Corticosteroids (Systemic) may diminish the therapeutic effect of Brincidofovir. Risk C: Monitor therapy
Calcitriol (Systemic): Corticosteroids (Systemic) may diminish the therapeutic effect of Calcitriol (Systemic). Risk C: Monitor therapy
Cladribine: Corticosteroids (Systemic) may enhance the immunosuppressive effect of Cladribine. Risk X: Avoid combination
Coccidioides immitis Skin Test: Corticosteroids (Systemic) may diminish the diagnostic effect of Coccidioides immitis Skin Test. Management: Consider discontinuing systemic corticosteroids (dosed at 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks) several weeks prior to coccidioides immitis skin antigen testing. Risk D: Consider therapy modification
Corticorelin: Corticosteroids (Systemic) may diminish the therapeutic effect of Corticorelin. Specifically, the plasma ACTH response to corticorelin may be blunted by recent or current corticosteroid therapy. Risk C: Monitor therapy
Cosyntropin: Corticosteroids (Systemic) may diminish the diagnostic effect of Cosyntropin. Risk C: Monitor therapy
COVID-19 Vaccine (Adenovirus Vector): Corticosteroids (Systemic) may diminish the therapeutic effect of COVID-19 Vaccine (Adenovirus Vector). Risk C: Monitor therapy
COVID-19 Vaccine (Inactivated Virus): Corticosteroids (Systemic) may diminish the therapeutic effect of COVID-19 Vaccine (Inactivated Virus). Risk C: Monitor therapy
COVID-19 Vaccine (mRNA): Corticosteroids (Systemic) may diminish the therapeutic effect of COVID-19 Vaccine (mRNA). Management: Consider administration of a 3rd dose of COVID-19 vaccine, at least 28 days after completion of the primary 2-dose series, in patients 5 years of age or older taking immunosuppressive therapies. Risk D: Consider therapy modification
COVID-19 Vaccine (Subunit): Corticosteroids (Systemic) may diminish the therapeutic effect of COVID-19 Vaccine (Subunit). Risk C: Monitor therapy
Deferasirox: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased. Risk C: Monitor therapy
Dengue Tetravalent Vaccine (Live): Corticosteroids (Systemic) may enhance the adverse/toxic effect of Dengue Tetravalent Vaccine (Live). Specifically, the risk of vaccine associated infection may be increased. Corticosteroids (Systemic) may diminish the therapeutic effect of Dengue Tetravalent Vaccine (Live). Risk X: Avoid combination
Denosumab: May enhance the immunosuppressive effect of Corticosteroids (Systemic). Management: Consider the risk of serious infections versus the potential benefits of coadministration of denosumab and systemic corticosteroids. If combined, monitor patients for signs/symptoms of serious infections. Risk D: Consider therapy modification
Desirudin: Corticosteroids (Systemic) may enhance the anticoagulant effect of Desirudin. More specifically, corticosteroids may increase hemorrhagic risk during desirudin treatment. Management: Discontinue treatment with systemic corticosteroids prior to desirudin initiation. If concomitant use cannot be avoided, monitor patients receiving these combinations closely for clinical and laboratory evidence of excessive anticoagulation. Risk D: Consider therapy modification
Desmopressin: Corticosteroids (Systemic) may enhance the hyponatremic effect of Desmopressin. Risk X: Avoid combination
Echinacea: May diminish the therapeutic effect of Corticosteroids (Systemic). Management: Consider avoiding echinacea in patients receiving immunosuppressants, such as systemic corticosteroids. Doses more than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks are considered immunosuppressive. Risk D: Consider therapy modification
Estrogen Derivatives: May increase the serum concentration of Corticosteroids (Systemic). Risk C: Monitor therapy
Fosaprepitant: May increase the serum concentration of Corticosteroids (Systemic). The active metabolite aprepitant is likely responsible for this effect. Management: Reduce the dose of corticosteroids, such as dexamethasone or oral methylprednisolone, by 50% when coadministered with fosaprepitant. Reduce intravenous methylprednisolone doses by 25% during coadministration with fosaprepitant. Risk D: Consider therapy modification
Gallium Ga 68 Dotatate: Corticosteroids (Systemic) may diminish the diagnostic effect of Gallium Ga 68 Dotatate. Risk C: Monitor therapy
Growth Hormone Analogs: Corticosteroids (Systemic) may diminish the therapeutic effect of Growth Hormone Analogs. Growth Hormone Analogs may decrease serum concentrations of the active metabolite(s) of Corticosteroids (Systemic). Risk C: Monitor therapy
Hyaluronidase: Corticosteroids (Systemic) may diminish the therapeutic effect of Hyaluronidase. Management: Patients receiving corticosteroids (particularly at larger doses) may not experience the desired clinical response to standard doses of hyaluronidase. Larger doses of hyaluronidase may be required. Risk D: Consider therapy modification
Immune Checkpoint Inhibitors: Corticosteroids (Systemic) may diminish the therapeutic effect of Immune Checkpoint Inhibitors. Management: Carefully consider the need for corticosteroids, at doses of a prednisone-equivalent of 10 mg or more per day, during the initiation of immune checkpoint inhibitor therapy. Use of corticosteroids to treat immune related adverse events is still recommended Risk D: Consider therapy modification
Indium 111 Capromab Pendetide: Corticosteroids (Systemic) may diminish the diagnostic effect of Indium 111 Capromab Pendetide. Risk X: Avoid combination
Inebilizumab: Corticosteroids (Systemic) may enhance the immunosuppressive effect of Inebilizumab. Risk C: Monitor therapy
Influenza Virus Vaccines: Corticosteroids (Systemic) may diminish the therapeutic effect of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiation of systemic corticosteroids at immunosuppressive doses. Influenza vaccines administered less than 14 days prior to or during such therapy should be repeated 3 months after therapy. Risk D: Consider therapy modification
Isoniazid: Corticosteroids (Systemic) may decrease the serum concentration of Isoniazid. Risk C: Monitor therapy
Leflunomide: Corticosteroids (Systemic) may enhance the immunosuppressive effect of Leflunomide. Management: Increase the frequency of chronic monitoring of platelet, white blood cell count, and hemoglobin or hematocrit to monthly, instead of every 6 to 8 weeks, if leflunomide is coadministered with immunosuppressive agents, such as systemic corticosteroids. Risk D: Consider therapy modification
Licorice: May increase the serum concentration of Corticosteroids (Systemic). Risk C: Monitor therapy
Loop Diuretics: Corticosteroids (Systemic) may enhance the hypokalemic effect of Loop Diuretics. Risk C: Monitor therapy
Lutetium Lu 177 Dotatate: Corticosteroids (Systemic) may diminish the therapeutic effect of Lutetium Lu 177 Dotatate. Management: Avoid repeated use of high-doses of corticosteroids during treatment with lutetium Lu 177 dotatate. Use of corticosteroids is still permitted for the treatment of neuroendocrine hormonal crisis. The effects of lower corticosteroid doses is unknown. Risk D: Consider therapy modification
Macimorelin: Corticosteroids (Systemic) may diminish the diagnostic effect of Macimorelin. Risk X: Avoid combination
Mifamurtide: Corticosteroids (Systemic) may diminish the therapeutic effect of Mifamurtide. Risk X: Avoid combination
MiFEPRIStone: May diminish the therapeutic effect of Corticosteroids (Systemic). MiFEPRIStone may increase the serum concentration of Corticosteroids (Systemic). Management: Avoid mifepristone in patients who require long-term corticosteroid treatment of serious illnesses or conditions (eg, for immunosuppression following transplantation). Corticosteroid effects may be reduced by mifepristone treatment. Risk X: Avoid combination
Natalizumab: Corticosteroids (Systemic) may enhance the immunosuppressive effect of Natalizumab. Risk X: Avoid combination
Neuromuscular-Blocking Agents (Nondepolarizing): May enhance the adverse neuromuscular effect of Corticosteroids (Systemic). Increased muscle weakness, possibly progressing to polyneuropathies and myopathies, may occur. Management: If concomitant therapy is required, use the lowest dose for the shortest duration to limit the risk of myopathy or neuropathy. Monitor for new onset or worsening muscle weakness, reduction or loss of deep tendon reflexes, and peripheral sensory decriments Risk D: Consider therapy modification
Nicorandil: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nicorandil. Gastrointestinal perforation has been reported in association with this combination. Risk C: Monitor therapy
Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective): Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective). Risk C: Monitor therapy
Nonsteroidal Anti-Inflammatory Agents (Nonselective): Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents (Nonselective). Risk C: Monitor therapy
Nonsteroidal Anti-Inflammatory Agents (Topical): May enhance the adverse/toxic effect of Corticosteroids (Systemic). Specifically, the risk of gastrointestinal bleeding, ulceration, and perforation may be increased. Risk C: Monitor therapy
Ocrelizumab: Corticosteroids (Systemic) may enhance the immunosuppressive effect of Ocrelizumab. Risk C: Monitor therapy
Ofatumumab: Corticosteroids (Systemic) may enhance the immunosuppressive effect of Ofatumumab. Risk C: Monitor therapy
Pidotimod: Corticosteroids (Systemic) may diminish the therapeutic effect of Pidotimod. Risk C: Monitor therapy
Pimecrolimus: May enhance the immunosuppressive effect of Corticosteroids (Systemic). Risk X: Avoid combination
Pneumococcal Vaccines: Corticosteroids (Systemic) may diminish the therapeutic effect of Pneumococcal Vaccines. Risk C: Monitor therapy
Poliovirus Vaccine (Live/Trivalent/Oral): Corticosteroids (Systemic) may enhance the adverse/toxic effect of Poliovirus Vaccine (Live/Trivalent/Oral). Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may diminish the therapeutic effect of Poliovirus Vaccine (Live/Trivalent/Oral). Risk X: Avoid combination
Polymethylmethacrylate: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Polymethylmethacrylate. Specifically, the risk for hypersensitivity or implant clearance may be increased. Management: Use caution when considering use of bovine collagen-containing implants such as the polymethylmethacrylate-based Bellafill brand implant in patients who are receiving immunosuppressants. Consider use of additional skin tests prior to administration. Risk D: Consider therapy modification
Quinolones: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Quinolones. Specifically, the risk of tendonitis and tendon rupture may be increased. Risk C: Monitor therapy
Rabies Vaccine: Corticosteroids (Systemic) may diminish the therapeutic effect of Rabies Vaccine. Management: Complete rabies vaccination at least 2 weeks before initiation of immunosuppressant therapy if possible. If post-exposure rabies vaccination is required during immunosuppressant therapy, administer a 5th dose of vaccine and check for rabies antibodies. Risk D: Consider therapy modification
Ritodrine: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Ritodrine. Risk C: Monitor therapy
Rubella- or Varicella-Containing Live Vaccines: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may diminish the therapeutic effect of Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination
Ruxolitinib (Topical): Corticosteroids (Systemic) may enhance the immunosuppressive effect of Ruxolitinib (Topical). Risk X: Avoid combination
Salicylates: May enhance the adverse/toxic effect of Corticosteroids (Systemic). These specifically include gastrointestinal ulceration and bleeding. Corticosteroids (Systemic) may decrease the serum concentration of Salicylates. Withdrawal of corticosteroids may result in salicylate toxicity. Risk C: Monitor therapy
Sargramostim: Corticosteroids (Systemic) may enhance the therapeutic effect of Sargramostim. Specifically, corticosteroids may enhance the myeloproliferative effects of sargramostim. Risk C: Monitor therapy
Sipuleucel-T: Corticosteroids (Systemic) may diminish the therapeutic effect of Sipuleucel-T. Management: Consider reducing the dose or discontinuing immunosuppressants, such as systemic corticosteroids, prior to initiating sipuleucel-T therapy. Doses equivalent to more than 2 mg/kg or 20 mg/day of prednisone given for 2 or more weeks are immunosuppressive. Risk D: Consider therapy modification
Solriamfetol: May enhance the hypertensive effect of Hypertension-Associated Agents. Risk C: Monitor therapy
Sphingosine 1-Phosphate (S1P) Receptor Modulator: May enhance the immunosuppressive effect of Corticosteroids (Systemic). Risk C: Monitor therapy
Succinylcholine: Corticosteroids (Systemic) may enhance the neuromuscular-blocking effect of Succinylcholine. Risk C: Monitor therapy
Tacrolimus (Systemic): Corticosteroids (Systemic) may decrease the serum concentration of Tacrolimus (Systemic). Conversely, when discontinuing corticosteroid therapy, tacrolimus concentrations may increase. Risk C: Monitor therapy
Tacrolimus (Topical): Corticosteroids (Systemic) may enhance the immunosuppressive effect of Tacrolimus (Topical). Risk X: Avoid combination
Talimogene Laherparepvec: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Talimogene Laherparepvec. Specifically, the risk of infection from the live, attenuated herpes simplex virus contained in talimogene laherparepvec may be increased. Risk X: Avoid combination
Tertomotide: Corticosteroids (Systemic) may diminish the therapeutic effect of Tertomotide. Risk X: Avoid combination
Thiazide and Thiazide-Like Diuretics: Corticosteroids (Systemic) may enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics. Risk C: Monitor therapy
Tisagenlecleucel: Corticosteroids (Systemic) may diminish the therapeutic effect of Tisagenlecleucel. Management: Avoid use of corticosteroids as premedication or at any time during treatment with tisagenlecleucel, except in the case of life-threatening emergency (such as resistant cytokine release syndrome). Risk D: Consider therapy modification
Tofacitinib: Corticosteroids (Systemic) may enhance the immunosuppressive effect of Tofacitinib. Management: Coadministration of tofacitinib with potent immunosuppressants is not recommended. Doses equivalent to more than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks are considered immunosuppressive. Risk D: Consider therapy modification
Typhoid Vaccine: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Typhoid Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may diminish the therapeutic effect of Typhoid Vaccine. Risk X: Avoid combination
Upadacitinib: Corticosteroids (Systemic) may enhance the immunosuppressive effect of Upadacitinib. Management: Coadministration of upadacitinib with systemic corticosteroids at doses equivalent to greater than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks. Risk D: Consider therapy modification
Urea Cycle Disorder Agents: Corticosteroids (Systemic) may diminish the therapeutic effect of Urea Cycle Disorder Agents. More specifically, Corticosteroids (Systemic) may increase protein catabolism and plasma ammonia concentrations, thereby increasing the doses of Urea Cycle Disorder Agents needed to maintain these concentrations in the target range. Risk C: Monitor therapy
Vaccines (Inactivated): Corticosteroids (Systemic) may diminish the therapeutic effect of Vaccines (Inactivated). Management: Administer vaccines at least 2 weeks prior to immunosuppressive corticosteroids if possible. If patients are vaccinated less than 14 days prior to or during such therapy, repeat vaccination at least 3 months after therapy if immunocompetence restored. Risk D: Consider therapy modification
Vaccines (Live): Corticosteroids (Systemic) may enhance the adverse/toxic effect of Vaccines (Live). Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may diminish the therapeutic effect of Vaccines (Live). Management: Avoid live vaccines during and for 1 month after therapy with immunosuppressive doses of corticosteroids (equivalent to prednisone > 2 mg/kg or 20 mg/day in persons over 10 kg for at least 2 weeks). Give live vaccines prior to therapy whenever possible. Risk D: Consider therapy modification
Vitamin K Antagonists (eg, warfarin): Corticosteroids (Systemic) may enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
Yellow Fever Vaccine: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Yellow Fever Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may diminish the therapeutic effect of Yellow Fever Vaccine. Risk X: Avoid combination
Endogenous corticotropin concentrations are increased near delivery (Smith 2007).
Corticotropin stimulates an endogenous steroid response; outcomes observed following systemic corticosteroid use during pregnancy may be relevant. Some studies have shown an association between first trimester systemic corticosteroid use and oral clefts; however, information is conflicting and may be influenced by maternal dose, duration/frequency of exposure, and indication for use. Additional data are needed to evaluate any potential risk of systemic corticosteroids and other adverse pregnancy outcomes (eg, gestational diabetes mellitus, low birth weight, preeclampsia, preterm birth) (ACOG 2019; Bandoli 2017; Lunghi 2010; Skuladottir 2014). Hypoadrenalism may occur in newborns following maternal use of corticosteroids in pregnancy; monitor.
It is not known if corticotropin is present in breast milk.
According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and the benefits of treatment to the mother.
May require increased dietary or supplemental intake of potassium; may require decreased dietary intake of sodium.
Blood pressure, cardiac function, weight; serum glucose, electrolytes; signs of adrenal insufficiency; signs of Cushing syndrome; secondary ocular infections
Following prolonged use: Bone mass density, growth in children, signs and symptoms of infection, cataract formation
Following discontinuation: Signs of infection, cardiac function, blood pressure, serum glucose, body weight, fecal blood
Stimulates the adrenal cortex to secrete adrenal steroids (including cortisol), weakly androgenic substances, and aldosterone. Prolonged administration of large doses induces hyperplasia and hypertrophy of the adrenal cortex and continuous high output of cortisol, corticosterone, and weak androgens. Trophic effects on the adrenal cortex appear to be mediated by cyclic adenosine monophosphate. Also reported to bind to melanocortin receptors.
Onset: Maximum effect: Cortisol serum concentration: IM, SUBQ: 3 to 12 hours.
Duration of action: Repository: 10 to 25 hours, up to 3 days.
Absorption: IM: Over 8 to 16 hours.
Half-life elimination: ACTH: 15 minutes.
Excretion: Urine.
Gel (Acthar Injection)
80 units/mL (per mL): $9,950.16
Gel (Cortrophin Injection)
80 units/mL (per mL): $7,644.40
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