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Chandra T, Aggarwal R. A Narrative Review of Acthar Gel for the Treatment of Myositis. Rheumatol Ther 2023; 10:523-537. [PMID: 36966453 PMCID: PMC10140234 DOI: 10.1007/s40744-023-00545-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/28/2023] [Indexed: 03/27/2023] Open
Abstract
Idiopathic inflammatory myopathies (IIMs) are autoimmune disorders characterized by symmetric proximal muscle weakness and chronic inflammation, with an increased risk of morbidity and mortality. The current standard of care includes traditional immunosuppressive pharmacotherapies; however, some patients cannot tolerate or do not adequately respond to these therapies, highlighting the need for alternative treatments for refractory disease. Acthar® Gel (repository corticotropin injection) is a naturally sourced mixture of adrenocorticotropic hormone analogs and other pituitary peptides that has been approved by the US Food and Drug Administration since 1952 for use in patients with two subgroups of IIMs, dermatomyositis (DM) and polymyositis (PM). However, it has not been routinely used in the treatment of IIMs. While Acthar may induce steroidogenesis, it also has a steroid-independent mechanism of action by exerting immunomodulatory effects through the activation of melanocortin receptors on immune cells, such as macrophages, B cells, and T cells. Recent clinical trials, retrospective analyses, and case reports add to the growing evidence suggesting that Acthar may be effective in patients with DM and PM. Here we review the current evidence supporting the safety and efficacy of Acthar for the treatment of refractory DM and PM.
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Affiliation(s)
| | - Rohit Aggarwal
- University of Pittsburgh, 3601 5th Avenue, Suite 2B, Pittsburgh, PA, 15261, USA.
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Kulkarni S, Durham H, Glover L, Ather O, Phillips V, Nemes S, Cousens L, Blomgran P, Ambery P. Metabolic adverse events associated with systemic corticosteroid therapy-a systematic review and meta-analysis. BMJ Open 2022; 12:e061476. [PMID: 36549729 PMCID: PMC9772659 DOI: 10.1136/bmjopen-2022-061476] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To assess the risk of new-onset or worsening hyperglycaemia, hypertension, weight gain and hyperlipidaemia with systemic corticosteroid therapy (CST) as reported in published randomised control trial (RCT) studies. DATA SOURCES Literature search using MEDLINE, EMBASE, Cochrane library, Web of Science and Scopus STUDY ELIGIBILITY CRITERIA: Published articles on results of RCT with a systemic CST arm with numerical data presented on adverse effect (AE). PARTICIPANTS AND INTERVENTIONS Reports of hyperglycaemia, hypertension, weight gain and hyperlipidaemia associated with systemic CST in patients or healthy volunteer's ≥17 years of age. STUDY APPRAISAL METHODS Risk of bias tool, assessment at the level of AE and key study characteristics. RESULTS A total of 5446 articles were screened to include 118 studies with 152 systemic CST arms (total participants=17 113 among which 8569 participants treated with CST). Pooled prevalence of hyperglycaemia in the CST arms within the studies was 10% (95% CI 7% to 14%), with the highest prevalence in respiratory illnesses at 22% (95% CI 9% to 35%). Pooled prevalence of severe hyperglycaemia, hypertension, weight gain and hyperlipidaemia within the corticosteroid arms was 5% (95% CI 2% to 9%), 6% (95% CI 4% to 8%), 13% (95% CI 8% to 18%), 8% (95% CI 4% to 17%), respectively. CST was significantly associated hyperglycaemia, hypertension and weight gain as noted in double-blinded placebo-controlled parallel-arms studies: OR of 2.13 (95% CI 1.66 to 2.72), 1.68 (95% CI 0.96 to 2.95) and 5.20 (95% CI 2.10 to 12.90), respectively. Intravenous therapy posed higher risk than oral therapy: OR of 2.39 (95% CI 1.16 to 4.91). LIMITATIONS There was significant heterogeneity in the AE definitions and quality of AE reporting in the primary studies and patient populations in the studies. The impact of cumulative dose effect on incidental AE could not be calculated. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Systemic CST use is associated with increased risk of metabolic AEs, which differs for each disease group and route of administration. PROSPERO REGISTRATION NUMBER CRD42020161270.
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Affiliation(s)
- Spoorthy Kulkarni
- Clinical Pharmacology and Therapeutics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Hannah Durham
- Department of Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Luke Glover
- Department of Medicine, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Osaid Ather
- Structural & Chemical Biology, The Francis Crick Institute, London, UK
| | - Veronica Phillips
- Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Szilard Nemes
- Data Science & AI, R&D BioPharmaceuticals, AstraZeneca, Gothenburg, Sweden
| | - Leslie Cousens
- Respiratory & Immunology, AstraZeneca R&D Boston, Waltham, Massachusetts, USA
| | - Parmis Blomgran
- Early Respiratory & Immunology, AstraZeneca R&D Gothenburg, Mölndal, Sweden
| | - Philip Ambery
- Late CVRM Research, AstraZeneca R&D Gothenburg, Mölndal, Sweden
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Namaei P, Ghadiri F, Jamali R, Azimi AR, Farhadi Shabestari HR, Vahabizad F. Evaluation of liver injury in multiple sclerosis patients receiving pulsed steroid therapy. Mult Scler Relat Disord 2022; 65:103968. [DOI: 10.1016/j.msard.2022.103968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 05/30/2022] [Accepted: 06/13/2022] [Indexed: 10/18/2022]
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Wynn D, Goldstick L, Bauer W, Zhao E, Tarau E, Cohen JA, Robertson D, Miller A. Results from a multicenter, randomized, double-blind, placebo-controlled study of repository corticotropin injection for multiple sclerosis relapse that did not adequately respond to corticosteroids. CNS Neurosci Ther 2022; 28:364-371. [PMID: 34984839 PMCID: PMC8841301 DOI: 10.1111/cns.13789] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/12/2021] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION About 20%-35% of multiple sclerosis (MS) patients fail to respond to high-dose corticosteroids during a relapse. Repository corticotropin injection (RCI, Acthar® Gel) is a naturally sourced complex mixture of adrenocorticotropic hormone analogs and pituitary peptides that has anti-inflammatory and immunomodulatory effects. AIMS The study objective was to determine the efficacy and safety of RCI in patients with MS relapse that inadequately responded to corticosteroids. This was a multicenter, double-blind, placebo-controlled study. Nonresponders to high-dose corticosteroids were randomized to receive RCI (80 U) or placebo daily for 14 days. Assessments included improvements on the Expanded Disability Status Scale (EDSS), Multiple Sclerosis Impact Scale (MSIS-29), Clinical Global Impression of Improvement (CGI-I), and adverse events (AEs). RESULTS Eighteen patients received RCI, and 17 received placebo. A greater proportion of EDSS responders was observed in the RCI group at Day 7, 21, and 42 compared with the placebo group. Qualitative CGI-I showed that more patients receiving RCI were much improved or very much improved than with placebo. No meaningful differences were observed between treatment groups for MSIS-29. No serious AEs or deaths were reported. CONCLUSION RCI is safe and effective for MS relapse patients who do not respond to high-dose corticosteroids.
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Affiliation(s)
- Daniel Wynn
- Consultants in Neurology, Multiple Sclerosis Center, Northbrook, Illinois, USA
| | - Lawrence Goldstick
- University of Cincinnati Waddell Center for Multiple Sclerosis, Cincinnati, Ohio, USA
| | - William Bauer
- Department of Neurosciences, University of Toledo, Toledo, Ohio, USA
| | - Enxu Zhao
- Mallinckrodt Pharmaceuticals, Hampton, New Jersey, USA
| | - Eva Tarau
- Mallinckrodt Pharmaceuticals, Hampton, New Jersey, USA
| | | | - Derrick Robertson
- Department of Neurology, University of South Florida, Tampa, Florida, USA
| | - Aaron Miller
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
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Berkovich R. Experience of Using Adrenocorticotropic Hormone in the Treatment of Patients With Acute Neuromyelitis Optica Who Failed Systemic Steroids: A Case Series. Clin Neuropharmacol 2020; 43:7-14. [PMID: 31876792 DOI: 10.1097/wnf.0000000000000373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Neuromyelitis optica (NMO) has a complex pathology. Clinical symptoms, derived from damage to optic nerves and spinal cord, cause optic neuritis and/or longitudinally extensive myelitis. Treatment options are limited. We assessed adrenocorticotropic hormone (ACTH) use in patients developing exacerbations on systemic steroid treatment and declining other treatments. METHODS Patients with NMO who initiated intravenous methylprednisolone (IVMP) for exacerbations and experienced a subsequent exacerbation on monthly IVMP or had inadequate response to IVMP received ACTH 80 U/d intramuscularly for 7 days (for acute relapse), followed by 80 U every 2 weeks (for long taper down/maintenance). Every 1 to 3 months, relapse, Expanded Disability Status Scale, laboratory, and adverse event assessments were performed. RESULTS Six patients (mean age: 48.6 years; NMO-suggestive clinical/imaging presentations; cerebral spinal fluid revealing no oligoclonal bands; aquaporin-4 positive [n = 5]) were identified: 5 experiencing subsequent exacerbations with monthly IVMP and 1 with inadequate response to IVMP. No relapses occurred during ACTH treatment or taper-down period, laboratory values indicated no safety concerns, and annual follow-up magnetic resonance imagings were stable. Adverse events were generally characterized as improved or unchanged versus with IVMP, although 1 patient reported transient edema (lower extremities) only during ACTH treatment. Potential treatment-related AEs included edema, acne, urinary tract infection, and insomnia and were reportedly less severe with ACTH treatment than IVMP. CONCLUSIONS Adrenocorticotropic hormone treatment for acute NMO was associated with clinical improvement, suggesting that ACTH could have a role in treating acute NMO patients failing IVMP and declining other treatments. Fewer/less severe AEs were observed with ACTH versus IVMP. Larger, controlled clinical studies are needed.
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Affiliation(s)
- Regina Berkovich
- Director and Founder, Regina Berkovich, MD, PhD, Inc. MAS Neurology, West Hollywood, CA and LAC+USC, Department of Neurology, Los Angeles, CA
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Abstract
INTRODUCTION Currently, there are no proven drugs that are FDA approved for the treatment of dermatomyositis (DM), even though multiple clinical trials are ongoing to evaluate safety and efficacy of novel therapeutics in DM. The purpose of this review is to highlight the biological plausibility, existing clinical evidence as well as completed and ongoing clinical trials for various drugs in pipeline for development for use in dermatomyositis. AREAS COVERED The drugs with the strongest evidence have been included in this review with a focus on the mechanism of their action pertaining to the disease process, clinical studies including completed and ongoing trials. With better understanding of the underlying pathophysiologic process, there are new molecular targets that have been identified that can be targeted by these novel drugs, predominantly biologic drugs. EXPERT OPINION There are various drugs being evaluated in phase II/III clinical trials that hold promise in DM. At the forefront of these are immunoglobulin, Lenabasum, and Abatacept for which phase III clinical trials are ongoing. In addition, promising clinical studies are ongoing or reported for KZR-616, anti-B cell therapy, anti-interferon drugs, and Repository Corticotrophin Injection (RCI).
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Affiliation(s)
- Tanya Chandra
- Internal Medicine Residency Program, University of Connecticut , Farmington, CT, USA
| | - Rohit Aggarwal
- Department of Medicine, Rheumatology and Clinical Immunology, University of Pittsburgh , Pittsburgh, PA, USA
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Hayes K, Warner E, Bollinger C, Wright D, Fitch RM. Repository corticotropin injection versus corticosteroids for protection against renal damage in a focal segmental glomerulosclerosis rodent model. BMC Nephrol 2020; 21:226. [PMID: 32539845 PMCID: PMC7296742 DOI: 10.1186/s12882-020-01879-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 06/02/2020] [Indexed: 12/30/2022] Open
Abstract
Background Focal segmental glomerulosclerosis (FSGS) causes renal fibrosis and may lead to kidney failure. FSGS and its common complication, proteinuria, are challenging to treat. Corticosteroids are ineffective in many patients with FSGS, and alternative treatments often yield suboptimal responses. Repository corticotropin injection (RCI; Acthar® Gel), a naturally sourced complex mixture of purified adrenocorticotropic hormone analogs and other pituitary peptides, may have beneficial effects on idiopathic FSGS via melanocortin receptor activation. Methods Two studies in a preclinical (female Sprague-Dawley rats) puromycin aminonucleoside FSGS model assessed the effect of RCI on renal function and morphology: an 8-week comparison of a single RCI dose with methylprednisolone (N = 27), and a 12-week chronic RCI dose range study (N = 34). Primary outcomes were proteinuria and renal pathology improvements for measures of renal fibrosis, tubular damage, glomerular injury, and total kidney injury score. Impact of RCI treatment was also determined by assessing urinary biomarkers for renal injury, podocyte expression of podoplanin (a biomarker for injury), podocyte effacement by electron microscopy, and histological staining for fibrosis biomarkers. Results Compared with saline treatment, RCI 30 IU/kg significantly reduced proteinuria, with a 38% reduction in peak mean urine protein levels on day 28 in the 8-week model, and RCI 10 IU/kg, 30 IU/kg, and 60 IU/kg reduced peak mean urine protein in the 12-week model by 18, 47, and 44%, respectively. RCI also showed significant dose-dependent improvements in fibrosis, interstitial inflammation, tubular injury, and glomerular changes. Total kidney injury score (calculated from histopathological evaluations) demonstrated statistically significant improvements with RCI 30 IU/kg in the 8-week study and RCI 60 IU/kg in the 12-week study. RCI treatment improved levels of urinary biomarkers of kidney injury (KIM-1 and OPN), expression of podoplanin, and podocyte morphology. RCI also reduced levels of desmin and fibrosis-associated collagen deposition staining. Methylprednisolone did not improve renal function or pathology in this model. Conclusions These results provide evidence supporting the improvement of FSGS with RCI, which was superior to corticosteroid treatment in this experimental model. To the authors’ knowledge, this is the first evidence that a drug for the treatment of FSGS supports podocyte recovery after repeated injury.
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Affiliation(s)
- Kyle Hayes
- Mallinckrodt Pharmaceuticals, 675 James S. McDonnell Blvd, 20-1-W, Hazelwood, MO, USA.
| | - Elizabeth Warner
- Mallinckrodt Pharmaceuticals, 675 James S. McDonnell Blvd, 20-1-W, Hazelwood, MO, USA
| | - Chris Bollinger
- Mallinckrodt Pharmaceuticals, 675 James S. McDonnell Blvd, 20-1-W, Hazelwood, MO, USA
| | - Dale Wright
- Mallinckrodt Pharmaceuticals, 675 James S. McDonnell Blvd, 20-1-W, Hazelwood, MO, USA
| | - Richard M Fitch
- Mallinckrodt Pharmaceuticals, 675 James S. McDonnell Blvd, 20-1-W, Hazelwood, MO, USA
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ACTH Treatment for Management of Nephrotic Syndrome: A Systematic Review and Reappraisal. Int J Nephrol 2020; 2020:2597079. [PMID: 32566293 PMCID: PMC7292987 DOI: 10.1155/2020/2597079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/07/2020] [Accepted: 04/29/2020] [Indexed: 01/15/2023] Open
Abstract
Background In recent years, the use of adrenocorticotropic hormone (ACTH) therapy for treatment of proteinuria due to nephrotic syndrome (NS) has been heavily explored. ACTH therapy, which comes in the natural (H. P. Acthar Gel) or synthetic (tetracosactide) form, has resulted in remission in patients with immunosuppressive and steroid-resistant NS. However, the exact efficacy of ACTH therapy in the NS etiologies, such as membranous nephropathy (MN), focal segmental glomerulosclerosis (FSGS), minimal change disease (MCD), lupus nephritis (LN), IgA nephropathy (IgAN), and membranoproliferative glomerulonephritis (MPGN), has not been determined. Objective This systematic review analyzed the published literature on ACTH therapy in various NS etiologies to determine its efficacy. Methods A comprehensive search of MEDLINE, EMBASE, and Cochrane databases was conducted for articles through June 2019. An additional search was performed on clinicaltrials.gov to search for additional trials and cross reference the results of our database search. The literature which studied synthetic or natural ACTH treatment in patients with known etiologies of NS was included. Studies were excluded when they consisted of a single case report or did not analyze the lone effect of ACTH in NS. Results The initial search yielded a total of 411 papers, and 22 papers were included. In 214 MN patients, there was an overall remission of 40% (85/214) and an overall remission of 43% (42/98) in FSGS patients. In other etiologies, there were overall remissions of 78% (11/14), 31% (5/16), 40% (16/40), and 62% (8/13) in MCD, LN, IgAN, and MPGN patients, respectively. Conclusion ACTH showed benefits in proteinuria reduction across all etiologies of NS. However, more randomized controlled studies with larger population sets and longer follow-ups are imperative to establish causal benefits. New studies into its efficacy in children are also necessary.
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Change in visual acuity and retinal structures following Repository Corticotropin Injection (RCI) therapy in patients with acute demyelinating optic neuritis: Improvement in low contrast visual acuity in both affected and contralateral eyes in a single-armed open-label study. J Neurol Sci 2019; 407:116505. [PMID: 31706456 DOI: 10.1016/j.jns.2019.116505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 08/22/2019] [Accepted: 09/19/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Current treatments after an episode of optic neuritis have limited success protecting the retinal nerves and restoring visual function. OBJECTIVE To assess the effectiveness of Repository Corticotropin Injection (RCI) after the onset of optic neuritis. METHODS Twenty-four adults were treated with RCI within 2 weeks of symptom onset. Seven exams over 400 days measured low- and high-contrast visual acuity (LCVA and HCVA) and spectral domain optical coherence tomography of the retinal structures. Differences between and among affected and contralateral eyes were assessed using linear mixed models. RESULTS HCVA improved in the affected eye over the study (36.2 letters to 52.5), and LCVA improved in both the affected eye (1.8 letters to 6.8) and the contralateral eye (8.3 letters to 11.7). These functional improvements occurred concurrent to a thinning in the papillomacular bundle and the ganglion cell, inner plexiform, and retinal nerve fiber layers, while the inner nuclear, outer plexiform, outer nuclear, and photoreceptor layers thickened. CONCLUSION The eyes affected by the ON and treated with RCI improved in both LCVA and HCVA, and unexpectedly LCVA improved in the contralateral eye as well. This functional improvement was mirrored by structural changes in the retina. This study lays the groundwork for future studies to explore potential neuro-protective and neuro-restorative effects of RCI.
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Hunter SF, Calkwood J, Kantor D. Optic neuritis: Both eyes improve after corticotropin. J Neurol Sci 2019; 407:116504. [PMID: 31753511 DOI: 10.1016/j.jns.2019.116504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/19/2019] [Indexed: 10/25/2022]
Affiliation(s)
| | | | - Daniel Kantor
- Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA; Medical Partnership 4 MS (MP4MS), LaBelle, FL, USA
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Costello J, Njue A, Lyall M, Heyes A, Mahler N, Philbin M, Nazareth T. Efficacy, safety, and quality-of-life of treatments for acute relapses of multiple sclerosis: results from a literature review of randomized controlled trials. Degener Neurol Neuromuscul Dis 2019; 9:55-78. [PMID: 31308790 PMCID: PMC6613013 DOI: 10.2147/dnnd.s208815] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 06/06/2019] [Indexed: 11/23/2022] Open
Abstract
Background Intravenous methylprednisolone (IVMP), repository corticotropin injection (RCI), plasmapheresis (PMP), and intravenous immunoglobulin (IVIG) are used in the treatment of acute multiple sclerosis (MS) relapse. A systematic literature review (SLR) of randomized controlled trials (RCTs) was conducted to examine the highest quality evidence available for these therapies. Methods English-language articles were searched in MEDLINE, Embase, and Cochrane Library through May 2016 per Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. MS conferences, SLRs, and bibliographies of included studies were also searched. Eligible studies included adults treated with ≥1 aforementioned therapy. Results Twenty-three RCTs were identified: 22 on efficacy, 11 on safety, and 3 on QOL (ie 18 IVMP, 2 RCI, 2 PMP, and 2 IVIG). IVMP and RCI improved relapse-related disability; however, IVIG and PMP showed inconsistent efficacy. QOL data were only ascertained for IVMP. Conclusions RCTs indicate IVMP and RCI are efficacious and well tolerated treatments for MS relapse. Overall, many RCTs were dated, with sample sizes of fewer than 30 patients and no definitions for relapse nor clinically significant change. Contemporary evidence generation for all relapse treatments of interest, across efficacy, safety, and QOL outcomes, is still needed.
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Affiliation(s)
- Jessica Costello
- Health Economics and Outcome Research/ Health Technology Assessment Services, RTI Health Solutions, Manchester, M20 2LS, UK
| | - Annete Njue
- Health Economics and Outcome Research/ Health Technology Assessment Services, RTI Health Solutions, Manchester, M20 2LS, UK
| | - Matthew Lyall
- Health Economics and Outcome Research/ Health Technology Assessment Services, RTI Health Solutions, Manchester, M20 2LS, UK
| | - Anne Heyes
- Health Economics and Outcome Research/ Health Technology Assessment Services, RTI Health Solutions, Manchester, M20 2LS, UK
| | - Nancy Mahler
- Health Economics and Outcome Research-Medical Science Liaison, Mallinckrodt Pharmaceuticals, Bedminister, NJ 07921, USA
| | - Michael Philbin
- Health Economics and Outcome Research-Medical Science Liaison, Mallinckrodt Pharmaceuticals, Bedminister, NJ 07921, USA
| | - Tara Nazareth
- Health Economics and Outcome Research, Mallinckrodt Pharmaceuticals, Bedminister, NJ 07921, USA
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Hartung DM, Johnston K, Deodhar A, Bourdette DN, Cohen DM. Repository Corticotropin Versus Glucocorticoid for Nephrotic Syndrome: When Will We See the Evidence? Am J Kidney Dis 2019; 74:256-262. [PMID: 30765104 DOI: 10.1053/j.ajkd.2018.12.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 12/04/2018] [Indexed: 01/13/2023]
Abstract
Despite little evidence supporting its superiority to glucocorticoid therapy, use and expenditures for repository corticotropin (rACTH) injection (H.P. Acthar Gel; Mallinckrodt) have increased dramatically in the last 5 years, particularly among a small number of nephrologists, rheumatologists, and neurologists. Recently, the manufacturer justified the extremely high and rapidly increasing cost of rACTH by citing the ongoing need to generate clinical data to support its use. We test this assertion by investigating the quality and provenance of the evidence likely to emerge in the foreseeable future. We identified all completed, in-progress, and proposed studies of rACTH registered at ClinicalTrials.gov. 75 studies representing 2,953 participants met inclusion criteria. Studies addressed primarily nephrologic (n = 23), rheumatologic (n = 28), and neurologic (n =22) indications. Of the 23 studies proposed for renal indications (enrollment, 33 ± 49 [mean ± SD]), 11 were not randomized, 8 compared only different rACTH treatment regimens, and 4 compared rACTH to placebo. No studies of rACTH proposed for renal indications included an rACTH-free arm receiving active treatment (ie, another form of immunosuppression). We conclude that evidence emerging in the foreseeable future is unlikely to broadly support rACTH use over lower-cost glucocorticoid-based alternatives for renal indications.
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Affiliation(s)
- Daniel M Hartung
- College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, OR
| | - Kirbee Johnston
- College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, OR
| | - Atul Deodhar
- Division of Rheumatology, Department of Medicine, Oregon Health & Science University, Portland, OR
| | - Dennis N Bourdette
- Department of Neurology, Oregon Health & Science University, Portland, OR; VA Portland Health Care System, Research Service, Portland, OR; MS Center of Excellence-West, VA Portland Health Care System, Portland, OR
| | - David M Cohen
- VA Portland Health Care System, Research Service, Portland, OR; Division of Nephrology and Hypertension, Department of Medicine, Oregon Health & Science University, Portland, OR.
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Nelson WW, Lima AF, Kranyak J, Opong-Owusu B, Ciepielewska G, Gallagher JR, Heap K, Carroll S. Retrospective Medical Record Review to Describe Use of Repository Corticotropin Injection Among Patients with Uveitis in the United States. J Ocul Pharmacol Ther 2019; 35:182-188. [PMID: 30676837 PMCID: PMC6479238 DOI: 10.1089/jop.2018.0090] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Introduction: Repository corticotropin injection (RCI) has immune-modulatory and anti-inflammatory effects and is approved for multiple indications, including severe and acute chronic allergic and inflammatory processes involving the eye and adnexa. This study describes patient characteristics, treatment patterns, and physicians' assessments of patients with uveitis treated with RCI. Methods: This was a retrospective medical record review of US patients. Eligible patients had a diagnosis of uveitis, received RCI in the past 12 months, and had completed or were receiving RCI treatment at the time of data collection. Baseline characteristics and after-treatment clinical data are descriptively reported. Results: The study included 91 patients (mean age 41 years, 62% female, and mean time since diagnosis 3.98 years). Most patients had moderate (n = 48, 53%) to severe (n = 21, 23%) visual impairment, and none was blind before RCI therapy. Patients used an average of 2.5 medications before RCI. Initial RCI dosing regimens, dose adjustments, and treatment durations were different for each patient. Concomitant medication use and dosages were reduced during RCI; 76 patients (84%) improved, 15 patients (16%) stayed the same, and none worsened; 86% of patients had improvements in vision. Conclusions: Physicians individualized RCI therapy among patients who suffered uveitis for several years and when previous therapies were inadequate. Most patients improved after initiating RCI, most commonly in vision. The findings support use of RCI for uveitis and provide a better understanding of patient characteristics and practice patterns to guide appropriate use.
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Affiliation(s)
| | | | - John Kranyak
- 1 Mallinckrodt Pharmaceuticals, Bedminster, New Jersey
| | | | | | | | - Kylee Heap
- 2 Clarity Pharma Research, LLC, Spartanburg, South Carolina
| | - Susan Carroll
- 2 Clarity Pharma Research, LLC, Spartanburg, South Carolina
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Kutz CF, Dix AL. Repository corticotropin injection in multiple sclerosis: an update. Neurodegener Dis Manag 2018; 8:217-225. [PMID: 29869572 DOI: 10.2217/nmt-2018-0008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Relapse management is a crucial component of multiple sclerosis care. Acute relapses are defined as new neurological symptoms or worsening of existing symptoms persisting for >24 h that are not attributable to heat, overexertion, or infection. The most commonly used treatment for multiple sclerosis relapse is a 3-5-day course of corticosteroids, primarily intravenous methylprednisolone with or without oral steroid taper. Repository corticotropin injection is also the US FDA-approved option for managing acute relapse, particularly in the patients with inadequate response, intolerability or allergy to corticosteroid treatment; poor venous access; or limited ability to receive home or clinic infusions.
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Affiliation(s)
- Christen F Kutz
- Colorado Springs Neurological Associates, 2312 N. Nevada Avenue, Colorado Springs, CO 80907, USA
| | - Amy L Dix
- Kansas City Multiple Sclerosis Center College Park Neurology, 10600 Mastin, Overland Park, KS 66208, USA
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Nociti V, Biolato M, De Fino C, Bianco A, Losavio FA, Lucchini M, Marrone G, Grieco A, Mirabella M. Liver injury after pulsed methylprednisolone therapy in multiple sclerosis patients. Brain Behav 2018; 8:e00968. [PMID: 29729087 PMCID: PMC5991562 DOI: 10.1002/brb3.968] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 03/06/2018] [Accepted: 03/11/2018] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES High-dose pulsed methylprednisolone-related liver injury cases have been reported in the literature, but a prospective study in patients with multiple sclerosis (MS) has never been performed. The aim of this study was to evaluate the prevalence and severity of liver injury in patients with MS after pulsed methylprednisolone therapy. METHODS We performed a prospective observational single-center study on patients with MS treated with i.v. methylprednisolone 1,000 mg/day for 5 days. We tested the liver functionality before and 2 weeks after the treatment. In case of severe liver injury, defined according to "Hy's law," a comprehensive hepatologic workup was performed. RESULTS During a 12-month observation period, we collected data on 251 cycles of i.v. steroid treatment of 175 patients with MS. After excluding eight cycles presenting a basal alteration of the biochemical liver tests, we observed a prevalence of 8.6% of liver injury in MS patients treated with pulsed methylprednisolone for clinical and neuroradiological relapses. In 2.5% of the patients, the liver injury was severe according to Hy's law; after a comprehensive hepatologic workup, three of them received a diagnosis of drug-induced liver injury and the other three of autoimmune hepatitis. CONCLUSIONS Liver injury after pulsed methylprednisolone therapy in patients with MS is not infrequent, and a close monitoring of aminotransferase level before treatment and 2 weeks later seems advisable.
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Affiliation(s)
- Viviana Nociti
- Multiple Sclerosis Center, Neuroscience Area, Neuroscience, Aging, Head and Neck and Orthopaedics Sciences Department, Fondazione Policlinico Universitario Gemelli, Catholic University of Sacred Heart, Rome, Italy.,Fondazione Don Gnocchi-ONLUS, Milan, Italy
| | - Marco Biolato
- Liver Transplant Medicine Unit, Gastroenterological Area, Gastroenterological and Endocrino-Metabolical Sciences Department, Fondazione Policlinico Universitario Gemelli, Catholic University of Sacred Heart, Rome, Italy
| | - Chiara De Fino
- Multiple Sclerosis Center, Neuroscience Area, Neuroscience, Aging, Head and Neck and Orthopaedics Sciences Department, Fondazione Policlinico Universitario Gemelli, Catholic University of Sacred Heart, Rome, Italy
| | - Assunta Bianco
- Multiple Sclerosis Center, Neuroscience Area, Neuroscience, Aging, Head and Neck and Orthopaedics Sciences Department, Fondazione Policlinico Universitario Gemelli, Catholic University of Sacred Heart, Rome, Italy
| | - Francesco Antonio Losavio
- Multiple Sclerosis Center, Neuroscience Area, Neuroscience, Aging, Head and Neck and Orthopaedics Sciences Department, Fondazione Policlinico Universitario Gemelli, Catholic University of Sacred Heart, Rome, Italy
| | - Matteo Lucchini
- Multiple Sclerosis Center, Neuroscience Area, Neuroscience, Aging, Head and Neck and Orthopaedics Sciences Department, Fondazione Policlinico Universitario Gemelli, Catholic University of Sacred Heart, Rome, Italy
| | - Giuseppe Marrone
- Liver Transplant Medicine Unit, Gastroenterological Area, Gastroenterological and Endocrino-Metabolical Sciences Department, Fondazione Policlinico Universitario Gemelli, Catholic University of Sacred Heart, Rome, Italy
| | - Antonio Grieco
- Liver Transplant Medicine Unit, Gastroenterological Area, Gastroenterological and Endocrino-Metabolical Sciences Department, Fondazione Policlinico Universitario Gemelli, Catholic University of Sacred Heart, Rome, Italy
| | - Massimiliano Mirabella
- Multiple Sclerosis Center, Neuroscience Area, Neuroscience, Aging, Head and Neck and Orthopaedics Sciences Department, Fondazione Policlinico Universitario Gemelli, Catholic University of Sacred Heart, Rome, Italy
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Melanocortins, Melanocortin Receptors and Multiple Sclerosis. Brain Sci 2017; 7:brainsci7080104. [PMID: 28805746 PMCID: PMC5575624 DOI: 10.3390/brainsci7080104] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/07/2017] [Accepted: 08/08/2017] [Indexed: 02/07/2023] Open
Abstract
The melanocortins and their receptors have been extensively investigated for their roles in the hypothalamo-pituitary-adrenal axis, but to a lesser extent in immune cells and in the nervous system outside the hypothalamic axis. This review discusses corticosteroid dependent and independent effects of melanocortins on the peripheral immune system, central nervous system (CNS) effects mediated through neuronal regulation of immune system function, and direct effects on endogenous cells in the CNS. We have focused on the expression and function of melanocortin receptors in oligodendroglia (OL), the myelin producing cells of the CNS, with the goal of identifying new therapeutic approaches to decrease CNS damage in multiple sclerosis as well as to promote repair. It is clear that melanocortin signaling through their receptors in the CNS has potential for neuroprotection and repair in diseases like MS. Effects of melanocortins on the immune system by direct effects on the circulating cells (lymphocytes and monocytes) and by signaling through CNS cells in regions lacking a mature blood brain barrier are clear. However, additional studies are needed to develop highly effective MCR targeted therapies that directly affect endogenous cells of the CNS, particularly OL, their progenitors and neurons.
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Gold LS, Suh K, Schepman PB, Damal K, Hansen RN. Healthcare Costs and Resource Utilization in Patients with Multiple Sclerosis Relapses Treated with H.P. Acthar Gel(®). Adv Ther 2016; 33:1279-92. [PMID: 27312977 PMCID: PMC4969319 DOI: 10.1007/s12325-016-0363-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Indexed: 12/03/2022]
Abstract
Introduction Multiple sclerosis (MS) is an autoimmune disorder with large annual costs. This study evaluated utilization and costs for the management of MS relapses with H.P. Acthar® Gel (repository corticotropin injection; Acthar; Mallinckrodt) compared to receipt of plasmapheresis (PMP) or intravenous immunoglobulin (IVIG) among patients with MS who experienced multiple relapses. Methods We identified patients with MS diagnoses who had relapses treated with intravenous methylprednisolone (IVMP), the first-line treatment for MS relapse. Patients who were treated for the subsequent relapses were eligible for the study. We analyzed 12- and 24-month healthcare utilization and costs among patients who received Acthar prescriptions compared to patients who were treated with PMP/IVIG using generalized linear and logistic regression models to calculate unadjusted and adjusted means and 95% confidence intervals. Results For the 12-month analysis, a total of 213 patients received Acthar prescriptions and 226 were treated with PMP or IVIG. Patients who received Acthar prescriptions were similar to those who received other treatments in terms of most demographic variables. Acthar recipients had fewer hospitalizations (0.2 vs. 0.4; P = 0.01) and received fewer outpatient services (29 vs. 43; P < 0.0001) but received more prescription medications (36 vs. 30; P < 0.0001) compared to recipients of PMP/IVIG. Patients who received Acthar prescriptions had lower inpatient and outpatient costs ($15,000 lower; P = 0.001; and $54,000 lower; P < 0.0001, respectively) but similar total costs. Similar results were seen in the cohort with 24 months of outcome data. Conclusion Acthar may be a useful treatment option compared to PMP/IVIG for patients with MS experiencing multiple relapses. Funding This study was funded by a grant to the University of Washington from Mallinckrodt Pharmaceuticals. Electronic supplementary material The online version of this article (doi:10.1007/s12325-016-0363-0) contains supplementary material, which is available to authorized users.
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Murray S, Woo A. Clinical experience with repository corticotropin injection in patients with multiple sclerosis experiencing mood changes with intravenous methylprednisolone: a case series. Ther Adv Neurol Disord 2015; 9:189-97. [PMID: 27134674 DOI: 10.1177/1756285615618642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The elevated prevalence of neuropsychiatric symptoms and disorders among patients with multiple sclerosis (MS) is well recognized, as are potential neuropsychiatric side effects of treatment with corticosteroids. Both methylprednisolone (MP) and repository corticotropin injection (HP Acthar(®) gel) have demonstrated efficacy in reducing short-term disability after exacerbations of MS. Although historical data are limited, repository corticotropin injection has not generally been associated with detrimental neuropsychiatric effects. We describe six cases of patients with relapsing-remitting MS who had previously experienced detrimental mood changes with MP treatment. Some of these patients had previous histories of mood disorders or other neuropsychiatric symptoms prior to MS diagnosis. All six patients were subsequently treated with repository corticotropin injection for MS exacerbations and each demonstrated improvements in MS symptoms. This clinical experience suggests that repository corticotropin injection should be considered as an alternative for patients who do not tolerate corticosteroids or have difficulties associated with intravenous medication. Furthermore, the rate of neuropsychiatric side effects observed in these patients was low. These observations support repository corticotropin injection as a viable alternative for the treatment of acute exacerbations of MS, particularly in patients who have a history of neuropsychiatric disorders or symptoms either independently or in response to MP treatment. In reviewing both the published data and our own clinical experience regarding potential neuropsychiatric adverse events with treatment for MS exacerbations, we hope to stimulate further research into the potential efficacy and safety of repository corticotropin injection among patients with some form of neuropsychiatric complications that must be considered when establishing a treatment plan for MS.
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Affiliation(s)
- Stacey Murray
- Neuro Institute of New England, 16 Chestnut Street, Suite 100, Foxboro, MA 02035, USA
| | - Andrew Woo
- Santa Monica Neurological Consultants, Santa Monica, CA, USA
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