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Kaplan J, Askanase A, Chu D, Abdellatif A, Basu D, Mirsaeidi M. Acthar ® Gel Treatment for Patients with Autoimmune and Inflammatory Diseases: An Historical Perspective and Characterization of Clinical Evidence. Clin Drug Investig 2023; 43:739-761. [PMID: 37792273 PMCID: PMC10575998 DOI: 10.1007/s40261-023-01303-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 10/05/2023]
Abstract
Acthar® Gel (repository corticotropin injection) is a naturally sourced complex mixture of adrenocorticotropic hormone analogs and other pituitary peptides that is believed to have both steroidogenic and nonsteroidogenic immunomodulatory effects via activation of melanocortin receptors in various cells throughout the body. Since 1952, Acthar has been approved by the US Food and Drug Administration to treat a variety of autoimmune and inflammatory diseases. Since 2014, Mallinckrodt Pharmaceuticals has conducted a large number of preclinical, clinical, and real-world-evidence studies of Acthar for the treatment of rheumatoid arthritis, systemic lupus erythematosus, dermatomyositis and polymyositis, multiple sclerosis relapse, ophthalmic disorders, sarcoidosis, and nephrotic syndrome. To date, Acthar has been the subject of more than 500 publications, many of which demonstrate the safety and efficacy of Acthar in patients with inflammatory diseases for whom standard treatments were ineffective or intolerable. Here, we review the history of Acthar and the findings of studies that have investigated the mechanism of action, safety, efficacy, and real-world effectiveness of Acthar for the treatment of inflammatory diseases.
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Affiliation(s)
- Jeffrey Kaplan
- Kansas City Multiple Sclerosis and Headache Center, 10600 Mastin Entrance C, Overland Park, KS, 66212, USA.
| | - Anca Askanase
- Columbia University Medical Center, New York, NY, USA
| | - David Chu
- Metropolitan Eye Research and Surgery Institute, Palisades Park, NJ, USA
| | | | - Dhiman Basu
- Heritage Rheumatology and Arthritis Care, Colleyville, TX, USA
| | - Mehdi Mirsaeidi
- College of Medicine-Jacksonville, University of Florida, Jacksonville, FL, USA
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Wu CLS, Cioanca AV, Gelmi MC, Wen L, Di Girolamo N, Zhu L, Natoli R, Conway RM, Petsoglou C, Jager MJ, McCluskey PJ, Madigan MC. The multifunctional human ocular melanocortin system. Prog Retin Eye Res 2023; 95:101187. [PMID: 37217094 DOI: 10.1016/j.preteyeres.2023.101187] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/24/2023]
Abstract
Immune privilege in the eye involves physical barriers, immune regulation and secreted proteins that together limit the damaging effects of intraocular immune responses and inflammation. The neuropeptide alpha-melanocyte stimulating hormone (α-MSH) normally circulates in the aqueous humour of the anterior chamber and the vitreous fluid, secreted by iris and ciliary epithelium, and retinal pigment epithelium (RPE). α-MSH plays an important role in maintaining ocular immune privilege by helping the development of suppressor immune cells and by activating regulatory T-cells. α-MSH functions by binding to and activating melanocortin receptors (MC1R to MC5R) and receptor accessory proteins (MRAPs) that work in concert with antagonists, otherwise known as the melanocortin system. As well as controlling immune responses and inflammation, a broad range of biological functions is increasingly recognised to be orchestrated by the melanocortin system within ocular tissues. This includes maintaining corneal transparency and immune privilege by limiting corneal (lymph)angiogenesis, sustaining corneal epithelial integrity, protecting corneal endothelium and potentially enhancing corneal graft survival, regulating aqueous tear secretion with implications for dry eye disease, facilitating retinal homeostasis via maintaining blood-retinal barriers, providing neuroprotection in the retina, and controlling abnormal new vessel growth in the choroid and retina. The role of melanocortin signalling in uveal melanocyte melanogenesis however remains unclear compared to its established role in skin melanogenesis. The early application of a melanocortin agonist to downregulate systemic inflammation used adrenocorticotropic hormone (ACTH)-based repository cortisone injection (RCI), but adverse side effects including hypertension, edema, and weight gain, related to increased adrenal gland corticosteroid production, impacted clinical uptake. Compared to ACTH, melanocortin peptides that target MC1R, MC3R, MC4R and/or MC5R, but not adrenal gland MC2R, induce minimal corticosteroid production with fewer amdverse systemic effects. Pharmacological advances in synthesising MCR-specific targeted peptides provide further opportunities for treating ocular (and systemic) inflammatory diseases. Following from these observations and a renewed clinical and pharmacological interest in the diverse biological roles of the melanocortin system, this review highlights the physiological and disease-related involvement of this system within human eye tissues. We also review the emerging benefits and versatility of melanocortin receptor targeted peptides as non-steroidal alternatives for inflammatory eye diseases such as non-infectious uveitis and dry eye disease, and translational applications in promoting ocular homeostasis, for example, in corneal transplantation and diabetic retinopathy.
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Affiliation(s)
- Chieh-Lin Stanley Wu
- School of Optometry and Vision Science, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Save Sight Institute and Ophthalmology, The Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Department of Optometry, Asia University, Taichung, Taiwan
| | - Adrian V Cioanca
- Save Sight Institute and Ophthalmology, The Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; John Curtin School of Medical Research, The Australian National University, ACT, Australia; ANU Medical School, The Australian National University, ACT, Australia
| | - Maria C Gelmi
- Department of Ophthalmology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Li Wen
- New South Wales Organ and Tissue Donation Service, Sydney Hospital and Sydney Eye Hospital, NSW, 2000, Australia
| | - Nick Di Girolamo
- School of Biomedical Sciences, Mechanisms of Disease and Translational Research, University of New South Wales, Sydney, Australia
| | - Ling Zhu
- Save Sight Institute and Ophthalmology, The Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Riccardo Natoli
- Save Sight Institute and Ophthalmology, The Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; John Curtin School of Medical Research, The Australian National University, ACT, Australia; ANU Medical School, The Australian National University, ACT, Australia
| | - R Max Conway
- Save Sight Institute and Ophthalmology, The Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Constantinos Petsoglou
- Save Sight Institute and Ophthalmology, The Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; New South Wales Organ and Tissue Donation Service, Sydney Hospital and Sydney Eye Hospital, NSW, 2000, Australia
| | - Martine J Jager
- Department of Ophthalmology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Peter J McCluskey
- Save Sight Institute and Ophthalmology, The Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Michele C Madigan
- School of Optometry and Vision Science, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Save Sight Institute and Ophthalmology, The Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
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Sharon Y, Anesi SD, Martinez CE, Huang AJW, Foster CS, Chu DS. Repository Corticotropin Injection as an Alternative Treatment for Refractory Ocular Mucous Membrane Pemphigoid. Cornea 2022; 41:45-51. [PMID: 34050065 DOI: 10.1097/ico.0000000000002771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/03/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to report the clinical course and outcome of patients with refractory ocular mucous membrane pemphigoid (MMP) treated by repository corticotropin injection (RCI). METHODS Patients with biopsy-proven ocular MMP treated with RCI from 3 tertiary medical centers were evaluated. Medical records between January 2013 and January 2021 were reviewed and deidentified to retrieve relevant disease-related data. Primary outcome measures included conjunctival inflammatory activity, change in Foster clinical conjunctival scarring staging after RCI treatment, and the development of ocular and systemic complications. RESULTS Included were 15 patients (10 women and 5 men; 36-95 yrs of age) with a mean follow-up of 4.5 years. Most of the patients (80%) had Foster stage 3 at presentation, and all patients had active MMP. Each patient had failed to respond to at least 1 immunomodulatory drug during the follow-up, and 9 (60%) patients had treatment failure of at least 2 other agents before the use of RCI. The mean duration of RCI treatment was 21 months (range, 3-54 mo). Foster stage did not change in any of the 15 patients at the last follow-up. Nine patients continued RCI therapy at the last follow-up, and in all of them, the disease activity of MMP was well controlled. No serious adverse events because of RCI were documented during the follow-up in any treated patient. CONCLUSIONS RCI may serve as an alternative or an adjunctive treatment in patients with severe and refractory ocular MMP. Treatment with RCI seems to be safe and well-tolerated.
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Affiliation(s)
- Yael Sharon
- Department of Ophthalmology, Rabin Medical Center, Petah-Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Metropolitan Eye Research and Surgery Institute, Palisades Park, NJ
| | - Stephen D Anesi
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham, MA
- Ocular Immunology and Uveitis Foundation (OIUF), Waltham, MA
| | - Christine E Martinez
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO
- Department of Ophthalmology and Visual Sciences, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Andrew J W Huang
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO
| | - Charles Stephen Foster
- Massachusetts Eye Research and Surgery Institution (MERSI), Waltham, MA
- Ocular Immunology and Uveitis Foundation (OIUF), Waltham, MA
- Department of Ophthalmology, Harvard Medical School, Boston, MA; and
| | - David S Chu
- Metropolitan Eye Research and Surgery Institute, Palisades Park, NJ
- Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, Newark, NJ
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Ocular mucous membrane pemphigoid: novel treatment strategies. Curr Opin Allergy Clin Immunol 2021; 21:486-492. [PMID: 34269741 DOI: 10.1097/aci.0000000000000767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To describe current treatments of ocular mucous membrane pemphigoid (OMMP), including conventional systemic immunosuppression (CIST) and novel biologic agents. RECENT FINDINGS CIST remains the main stay therapy for the management of OMMP. The choice of agents is tailored to disease severity - mild disease is treated with dapsone, whereas moderately severe cases are often treated with mycophenolate mofetil or sulfa-based drugs and severe cases are treated with cyclophosphamide. In recalcitrant disease newer biologics such as Rituximab, intravenous immunoglobins and tumour necrosis alpha antagonists have proven to be effective in disease control. Control of inflammation with topical therapy and halting conjunctival fibrosis remain as areas of unmet clinical needs. SUMMARY OMMP is largely treated with CIST. The recent introduction of new biologic agents could shape the way the disease is treated in the near future.
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Schmidt E, Rashid H, Marzano A, Lamberts A, Di Zenzo G, Diercks G, Alberti‐Violetti S, Barry R, Borradori L, Caproni M, Carey B, Carrozzo M, Cianchini G, Corrà A, Dikkers F, Feliciani C, Geerling G, Genovese G, Hertl M, Joly P, Meijer J, Mercadante V, Murrell D, Ormond M, Pas H, Patsatsi A, Rauz S, van Rhijn B, Roth M, Setterfield J, Zillikens D, C.Prost, Zambruno G, Horváth B, Caux F. European Guidelines (S3) on diagnosis and management of mucous membrane pemphigoid, initiated by the European Academy of Dermatology and Venereology - Part II. J Eur Acad Dermatol Venereol 2021; 35:1926-1948. [PMID: 34309078 PMCID: PMC8518905 DOI: 10.1111/jdv.17395] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/24/2021] [Indexed: 01/21/2023]
Abstract
This guideline has been initiated by the task force Autoimmune Blistering Diseases of the European Academy of Dermatology and Venereology, including physicians from all relevant disciplines and patient organizations. It is a S3 consensus-based guideline that systematically reviewed the literature on mucous membrane pemphigoid (MMP) in the MEDLINE and EMBASE databases until June 2019, with no limitations on language. While the first part of this guideline addressed methodology, as well as epidemiology, terminology, aetiology, clinical presentation and outcome measures in MMP, the second part presents the diagnostics and management of MMP. MMP should be suspected in cases with predominant mucosal lesions. Direct immunofluorescence microscopy to detect tissue-bound IgG, IgA and/or complement C3, combined with serological testing for circulating autoantibodies are recommended. In most patients, serum autoantibodies are present only in low levels and in variable proportions, depending on the clinical sites involved. Circulating autoantibodies are determined by indirect IF assays using tissue substrates, or ELISA using different recombinant forms of the target antigens or immunoblotting using different substrates. The major target antigen in MMP is type XVII collagen (BP180), although in 10-25% of patients laminin 332 is recognized. In 25-30% of MMP patients with anti-laminin 332 reactivity, malignancies have been associated. As first-line treatment of mild/moderate MMP, dapsone, methotrexate or tetracyclines and/or topical corticosteroids are recommended. For severe MMP, dapsone and oral or intravenous cyclophosphamide and/or oral corticosteroids are recommended as first-line regimens. Additional recommendations are given, tailored to treatment of single-site MMP such as oral, ocular, laryngeal, oesophageal and genital MMP, as well as the diagnosis of ocular MMP. Treatment recommendations are limited by the complete lack of high-quality randomized controlled trials.
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James H, Paley GL, Brasington R, Custer PL, Margolis TP, Paley MA. Tofacitinib for refractory ocular mucous membrane pemphigoid. Am J Ophthalmol Case Rep 2021; 22:101104. [PMID: 34007952 PMCID: PMC8111584 DOI: 10.1016/j.ajoc.2021.101104] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 01/18/2021] [Accepted: 04/11/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose To report the successful use of tofacitinib in the treatment of refractory ocular mucous membrane pemphigoid (MMP). Observations Two patients with ocular MMP presented with refractory disease after failure of multiple therapies. Treatment with tofacitinib led to durable control of conjunctival inflammation within 8 weeks and no apparent progression of sub-conjunctival fibrosis. One patient maintained absence of apparent disease activity over 16 months of follow-up. Cessation of tofacitinib in the other patient led to disease relapse which was reversed by re-initiation of therapy. Conclusions and importance Small molecule inhibitors of Janus kinases, such as tofacitinib, may offer an effective treatment option for refractory ocular MMP.
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Affiliation(s)
- Hayley James
- Department of Ophthalmology and Visual Sciences, Washington University in Saint Louis, Center for Outpatient Health, 6th floor, 4901 Forest Park Avenue, Saint Louis, MO, 63110, USA
| | - Grace L Paley
- Department of Ophthalmology and Visual Sciences, Washington University in Saint Louis, Center for Outpatient Health, 6th floor, 4901 Forest Park Avenue, Saint Louis, MO, 63110, USA
| | - Richard Brasington
- Department of Ophthalmology and Visual Sciences, Washington University in Saint Louis, Center for Outpatient Health, 6th floor, 4901 Forest Park Avenue, Saint Louis, MO, 63110, USA.,Division of Rheumatology, Department of Medicine, Washington University in Saint Louis, Center for Advanced Medicine, 5th floor Suite C, 4921 Parkview Place, Saint Louis, MO, 63110, USA
| | - Philip L Custer
- Department of Ophthalmology and Visual Sciences, Washington University in Saint Louis, Center for Outpatient Health, 6th floor, 4901 Forest Park Avenue, Saint Louis, MO, 63110, USA
| | - Todd P Margolis
- Department of Ophthalmology and Visual Sciences, Washington University in Saint Louis, Center for Outpatient Health, 6th floor, 4901 Forest Park Avenue, Saint Louis, MO, 63110, USA
| | - Michael A Paley
- Division of Rheumatology, Department of Medicine, Washington University in Saint Louis, Center for Advanced Medicine, 5th floor Suite C, 4921 Parkview Place, Saint Louis, MO, 63110, USA
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Crane AB, Sharon Y, Chu DS. Use of Adrenocorticotropic Hormone in Ophthalmology. J Ocul Pharmacol Ther 2020; 36:661-667. [PMID: 32762596 DOI: 10.1089/jop.2020.0039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The ability of the adrenocorticotropic hormone (ACTH) to induce steroidogenesis and upregulate anti-inflammatory processes has long been known. More recently, however, extrasteroidal mechanisms, through which ACTH exerts anti-inflammatory processes, have been described. This has renewed hope that ACTH can combat inflammatory conditions even when resistant to steroids. This review article summarizes the literature on the use of ACTH in ocular disease. Unfortunately, much of the data regarding the clinical utility of ACTH are outdated, with many studies published in the 1950s and 1960s. Many of these older studies are inconsistent or incomplete with their reporting, making it difficult to ascertain the meaning of the outcomes. Despite the limitations, 2 important trends are evident. First, when used to treat an inflammatory disease, ACTH can be effective at decreasing or eliminating ocular inflammation, even in a refractory disease resistant to multiple treatment modalities. Second, adverse effects of ACTH are rare and are most likely to be reported with relatively high doses of ACTH therapy. Taken as a whole, these studies offer initial promising data that ACTH may be a safe and effective alternative in refractory ocular inflammatory disease. However, they highlight an important lack of prospective data to more rigorously understand the true safety and efficacy of this therapy.
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Affiliation(s)
- Alexander B Crane
- Rutgers New Jersey Medical School, Institute of Ophthalmology and Visual Science, Rutgers University, Newark, New Jersey, USA
| | - Yael Sharon
- Department of Ophthalmology, Rabin Medical Center, Petah Tikva, Israel
| | - David S Chu
- Rutgers New Jersey Medical School, Institute of Ophthalmology and Visual Science, Rutgers University, Newark, New Jersey, USA.,Metropolitan Eye Research and Surgery Institute, Palisades Park, New Jersey, USA
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Chen E, Reynolds HH, Graham LV. Ocular cicatricial pemphigoid treated with intramuscular corticotropin injections. JAAD Case Rep 2020; 6:450-452. [PMID: 32382644 PMCID: PMC7200478 DOI: 10.1016/j.jdcr.2020.02.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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