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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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Wan GJ, Niewoehner J, Hayes K. Acthar Gel (RCI): A Narrative Literature Review of Clinical and Economic Evidence. CLINICOECONOMICS AND OUTCOMES RESEARCH 2023; 15:499-512. [PMID: 37397803 PMCID: PMC10312382 DOI: 10.2147/ceor.s410082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 05/24/2023] [Indexed: 07/04/2023] Open
Abstract
Acthar® Gel (repository corticotropin injection [RCI]) is a naturally sourced complex mixture of adrenocorticotropic hormone analogs and other pituitary peptides used to treat patients with serious and rare inflammatory and autoimmune conditions. This narrative review summarizes the key clinical and economic findings among 9 indications: infantile spasms (IS), multiple sclerosis (MS) relapses, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), dermatomyositis and polymyositis (DM/PM), ocular inflammatory diseases (primarily uveitis and severe keratitis), symptomatic sarcoidosis, and proteinuria in nephrotic syndrome (NS). Key studies of clinical efficacy and healthcare resource utilization and cost from 1956 to 2022 are discussed. Evidence supports the efficacy of RCI across all 9 indications. RCI is recommended as first-line treatment for IS and is associated with improved outcomes for the other 8 indications, including increased recovery rates in MS relapse; improved disease control in RA, SLE, and DM/PM; real-world effectiveness in patients with uveitis and severe keratitis; improved lung function and reduced corticosteroid use in symptomatic sarcoidosis; and increased rates of partial remission of proteinuria in NS. For many indications, RCI may improve clinical outcomes during exacerbations or when conventional treatments have failed to show a benefit. RCI is also associated with a reduction in the use of biologics, corticosteroids, and disease-modifying antirheumatic drugs. Economic data suggest RCI is a cost-effective, value-based treatment option for MS relapse, RA, and SLE. Other economic benefits have been demonstrated for IS, MS relapses, RA, SLE, and DM/PM, including reduced hospitalizations, lengths of stay, inpatient and outpatient services, and emergency department visits. RCI is considered safe and effective and features economic benefits for numerous indications. Its ability to control relapse and disease activity makes RCI an important nonsteroid treatment option that could help preserve functioning and well-being among patients with inflammatory and autoimmune conditions.
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Affiliation(s)
- George J Wan
- Mallinckrodt Pharmaceuticals, Bridgewater, NJ, USA
| | | | - Kyle Hayes
- Mallinckrodt Pharmaceuticals, Bridgewater, NJ, USA
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Meng Y, Chifeng L, Qinghuan Z, Zichan H, Jianmin L, Danqi D. Meta-analysis of clinical risk factors of patients with systemic lupus erythematosus complicated with invasive fungal infection. Medicine (Baltimore) 2023; 102:e29652. [PMID: 36930103 PMCID: PMC10019271 DOI: 10.1097/md.0000000000029652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 05/10/2022] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND To systematically evaluate the clinical risk factors of patients with systemic lupus erythematosus (SLE) complicated with invasive fungal infection (IFI) among patients. METHODS A meta-analysis was performed of all the literatures germane to estimate the clinical risk factors of patients with SLE complicated with IFI from published clinical trials from 1990 to April 2022. Mean differences, odds ratio and 95% confidence intervals were calculated, and the meta-analysis was conducted with Stata 12.0 software (StataCorp, College Station, TX). RESULTS A total of 14 clinical research involving 1129 patients were included. The results of meta-analysis demonstrated that immunosuppressant, glucocorticoids, systemic lupus erythematosus disease activity index score, antibiotic were risk factors associated with IFI in SLE patients. However, age, sex, course of disease, leukopenia, lymphopenia, C- reactive protein and hypoproteinemia were not the risk factors associated with IFI in patients with SLE. CONCLUSION Our results indicate that immunosuppressant, glucocorticoids, systemic lupus erythematosus disease activity index score, antibiotic were risk factors for IFI in SLE patients. However, high quality of multicenter, large sample size-controlled trials are needed to validate the result.
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Affiliation(s)
- Yang Meng
- Department of Dermatology, The Third Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Department of Dermatology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Liao Chifeng
- Institute of Dermatology and Department of Dermatology, No.1 Hospital, Anhui Medical University, Hefei, Anhui, China
| | - Zhu Qinghuan
- Department of Dermatology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Huang Zichan
- Department of Dermatology, The Third Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Li Jianmin
- Department of Dermatology, The Third Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Deng Danqi
- Department of Dermatology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
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Amalia L. Cerebral Venous Sinus Thrombosis induced By Hypercoagulation in Patient With Systemic Lupus Erythematosus: A Case Report and Literature Review. J Blood Med 2023; 14:1-6. [PMID: 36647371 PMCID: PMC9840394 DOI: 10.2147/jbm.s387075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 12/05/2022] [Indexed: 01/11/2023] Open
Abstract
Introduction Systemic lupus erythematous (SLE) are autoimmune diseases and cerebral venous sinus thrombosis (CVST) is coincidence regarding hypercoagulable condition of both diseases. The presence of both diseases in the same patient is rare, which suggests a relative incompatibility between these diseases. Case Presentation I report a female case with Systemic Lupus Erythematosus history, aged 27 years, with blurred vision, diplopia, severe headache, numbness and progressive right hemiparesis in 2 weeks. There was narrowing caliber at left transversus and right sigmoid sinus in magnetic resonance venography. She showed improvement in vision, numbness, headache and motor strength in right extremities after receiving pulse dose of corticosteroid for three days. Conclusion The distinction between SLE and CVST is a diagnostic challenge for the neurologist, and the presence of both diseases should be considered in patients with clinical neurologic manifestations who present with typical systemic manifestations of SLE and CVST. Neurogenic inflammation can induce disorders of the blood vessel wall (endothelium) that cause hypercoagulability and changes in acute vascular conditions can occur consisting of intraluminal platelet aggregation, thrombosis and also can cause total cerebral thrombotic venous or venular occlusion in SLE patients.
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Affiliation(s)
- Lisda Amalia
- Department of Neurology, Faculty Medicine, Universitas Padjadjaran/RSUP Dr. Hasan Sadikin Bandung, Bandung, Indonesia,Correspondence: Lisda Amalia, Jl. Pasteur 38, Bandung, Indonesia, Email
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Bindra J, Chopra I, Hayes K, Niewoehner J, Panaccio M, Wan GJ. Cost-Effectiveness of Acthar Gel Versus Standard of Care for the Treatment of Exacerbations in Moderate-to-Severe Systemic Lupus Erythematosus. Adv Ther 2023; 40:194-210. [PMID: 36266383 PMCID: PMC9859852 DOI: 10.1007/s12325-022-02332-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/21/2022] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Despite current standard of care (SoC), there is an unmet need for the treatment of active systemic lupus erythematosus (SLE). The study assessed the cost-effectiveness of Acthar® Gel (repository corticotropin injection) versus SoC treatment in patients with active, moderate-to-severe SLE from the US payer and societal perspectives over 2 and 3 years. METHODS Cost-effectiveness model was developed using a probabilistic cohort-level state-transition approach. Patients received Acthar Gel in an exacerbation state, and the outcomes were assessed at the end of a 3-month cycle for response achievement based on the probability of treatment success with Acthar Gel. Patients may sustain the response or experience an exacerbation. For the base case scenario, moderate-to-severe SLE was defined as British Isles Lupus Assessment Group (BILAG)-2004 ≥ 20 or SLE Disease Activity Index 2000 (SLEDAI-2K) ≥ 10 and clinical response was based on SLE responder index (SRI)-4. Clinical response, productivity loss, and utility were derived from a phase 4 SLE trial; cost and disutility estimates were sourced from the literature. RESULTS From a payer perspective, Acthar Gel versus SoC resulted in an incremental cost-effectiveness ratio (ICER) of $133,110 per quality-adjusted life-year (QALY) and $94,818 per QALY over 2 and 3 years, respectively. From a societal perspective, Acthar Gel versus SoC results in an ICER of $70,827 per QALY and $32,525 per QALY over 2 and 3 years, respectively. Results from the sensitivity and scenario analyses are consistent with those of the base case model. CONCLUSIONS Acthar Gel is a cost-effective, value-based treatment option for appropriate patients with moderate-to-severe SLE at a willingness-to-pay threshold of $150,000 over 2-3 years from the US payer and societal perspectives. Acthar Gel results in the reduction of direct medical and indirect costs.
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Affiliation(s)
- Jas Bindra
- Falcon Research Group, North Potomac, MD USA
| | | | - Kyle Hayes
- Mallinckrodt Pharmaceuticals, 53 Frontage Road, Hampton, NJ 08827 USA
| | - John Niewoehner
- Mallinckrodt Pharmaceuticals, 53 Frontage Road, Hampton, NJ 08827 USA
| | - Mary Panaccio
- Mallinckrodt Pharmaceuticals, 53 Frontage Road, Hampton, NJ 08827 USA
| | - George J. Wan
- Mallinckrodt Pharmaceuticals, 53 Frontage Road, Hampton, NJ 08827 USA
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Askanase AD, Furie RA. A Narrative Review of Repository Corticotropin Injection for the Treatment of Systemic Lupus Erythematosus. Adv Ther 2022; 39:3088-3103. [PMID: 35641860 PMCID: PMC9239929 DOI: 10.1007/s12325-022-02160-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/07/2022] [Indexed: 11/29/2022]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder that affects multiple organ systems. The most prevalent manifestations include constitutional symptoms, arthritis, and rash. An SLE flare is defined as a measurable increase in disease activity that may prompt a change in treatment. According to the European Alliance of Associations for Rheumatology guidance, SLE treatments should be aimed at reducing disease activity and flares, as well as preventing organ damage. Standard-of-care treatment of SLE includes glucocorticoids, but their long-term use is associated with damage accrual. Repository corticotropin injection (RCI; Acthar® Gel) is a naturally sourced complex mixture of adrenocorticotropic hormone analogs and other pituitary peptides that has anti-inflammatory and immunomodulatory effects beyond its steroidogenic effect, and has been US Food and Drug Administration–approved for the treatment of SLE flares and as a maintenance therapy. This review summarizes data from three clinical trials that evaluated the efficacy and safety of RCI in the treatment of patients with moderate–severe refractory SLE. These clinical trials confirmed that RCI improved global disease activity scores and some SLE clinical manifestations. Analysis of pooled data from these trials showed that RCI treatment significantly improved the British Isles Lupus Assessment Group 2004 (BILAG-2004) index scores after 8 weeks of treatment, and tender and swollen joint counts after 4 weeks. These clinical trials demonstrated an acceptable safety profile with few serious adverse events reported. The distinct mechanisms of action from standard-of-care therapies and the favorable safety and good efficacy profiles support the use of RCI as therapy for patients with refractory SLE.
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Affiliation(s)
- Anca D Askanase
- Columbia University Medical Center, 630 West 168th Street, P&S 3-3450, New York, NY, 10032, USA.
| | - Richard A Furie
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Girman C, Panaccio MP, Hayes K, Niewoehner J, Wan GJ. Pain and Fatigue Improvements in Patients Treated with Repository Corticotropin Injection Across Five Indications: A Narrative Review. Adv Ther 2022; 39:3072-3087. [PMID: 35635646 PMCID: PMC9239937 DOI: 10.1007/s12325-022-02176-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/29/2022] [Indexed: 11/28/2022]
Abstract
Repository corticotropin injection (RCI; Acthar® Gel) is approved by the US Food and Drug Administration (FDA) for use in 19 indications, including for the treatment of selected patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), symptomatic sarcoidosis, uveitis, and keratitis. Despite treatment with disease-modifying antirheumatic drugs, many patients with RA, SLE, and other chronic inflammatory rheumatic diseases continue to be affected by severe pain and fatigue, indicating a need for other therapies. To examine the clinical data regarding the impact of RCI treatment on pain and fatigue in selected populations, this review included English-language peer-reviewed publications of clinical trials of any size and cohort studies with more than 10 patients that included pain and/or fatigue based on patient-reported outcomes (PROs) and/or physician-assessed measures in adults following treatment with RCI for RA, SLE, symptomatic sarcoidosis, uveitis, or keratitis. Literature searches identified eight studies that met these criteria. Four studies (reported in five publications) were in patients with RA or SLE, two in patients with sarcoidosis, one in patients with uveitis, and one in patients with noninfectious keratitis. Across the different types of studies assessed (clinical trials, chart reviews, real-world evidence), the results were consistent with respect to the impact of RCI treatment on improving pain and fatigue. As summarized in this review, data from patient- and physician-reported outcome measures in eight studies demonstrate that, in addition to improving more traditional efficacy measures, RCI may also improve pain and fatigue in patients with RA, SLE, symptomatic sarcoidosis, uveitis, and noninfectious keratitis. Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are chronic autoimmune diseases. Clinical studies of drugs for these diseases do not often ask patients how they feel after treatment. Despite treatment, many people with these diseases have pain and feel tired. Repository corticotropin injection (RCI) is a prescription drug for patients with RA, SLE, and other chronic immune diseases. We reviewed the results of published studies with data on pain and fatigue from patients treated with RCI. Four studies were in patients with RA or SLE. Two studies were in patients with symptomatic sarcoidosis. One study was in patients with uveitis. One study was in patients with noninfectious keratitis. These eight studies show that adding RCI to standard treatment lowers pain and fatigue in some patients. It would be helpful to measure pain and fatigue in future clinical studies of drugs for patients with chronic immune diseases.
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Affiliation(s)
| | | | - Kyle Hayes
- Mallinckrodt Pharmaceuticals Inc., Hampton, NJ, USA
| | | | - George J Wan
- Mallinckrodt Pharmaceuticals Inc., Hampton, NJ, USA.
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Natural Adrenocorticotropic Hormone (ACTH) Relieves Acute Inflammation in Gout Patients by Changing the Function of Macrophages. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:9241835. [PMID: 35646298 PMCID: PMC9132716 DOI: 10.1155/2022/9241835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 02/28/2022] [Accepted: 03/03/2022] [Indexed: 11/27/2022]
Abstract
Gout is a common arthritis caused by deposition of monosodium urate crystals. Macrophage is crucial in the process of monosodium urate (MSU)-induced inflammation. Although it has been reported that adrenocorticotropic hormone (ACTH) in nature can be used to cure urarthritis, the mechanism concerning macrophage is still not clear. However, gout patients manifest other complications, such as hypertension, diabetes, chronic kidney disease, and hormone intolerance, which limit efficacy of some of these first-line drugs. Therefore, this study aims to explore how natural ACTH can alleviate urarthritis through functional changes in macrophage. We analyzed the variations in VAS pain scores of five patients, knowing the time of action and detecting the level of cortisol and ACTH in patients 24 hours after the application of ACTH. The effect of natural ACTH on joint inflammation and the level of cortisol in blood in the mouse model was evaluated by studies in vivo. In vitro studies, we evaluated the effect of natural ACTH on macrophages and revealed different functions of ACTH and dexamethasone on macrophages in the transcriptional level. In patients with acute gout, natural ACTH can quickly alleviate pain and does not affect the level of cortisol and ACTH. Natural ACTH is able to ease the swelling and inflammatory cell infiltration caused by arthritis, without changing the level of cortisol. Besides, natural ACTH in vitro can alleviate acute gouty inflammation by regulating phagocytosis and polarization of macrophage, which also exerts different effects on the transcription of some related genes. Natural ACTH is able to alleviate acute gouty inflammation by regulating macrophage, and this effect differs from that of dexamethasone at the transcriptional level.
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Tran KA, Harrod C, Bourdette DN, Cohen DM, Deodhar AA, Hartung DM. Characterization of the Clinical Evidence Supporting Repository Corticotropin Injection for FDA-Approved Indications: A Scoping Review. JAMA Intern Med 2022; 182:206-217. [PMID: 34902005 DOI: 10.1001/jamainternmed.2021.7171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Repository corticotropin injection is an expensive medication that was approved in 1952 for the treatment of many inflammatory conditions. The clinical evidence supporting the use of repository corticotropin (hereinafter referred to as corticotropin) has been weak, perhaps because its approval predated the modern review standards of the US Food and Drug Administration (FDA). OBJECTIVE To characterize the clinical evidence supporting the use of corticotropin for its FDA-approved indications. EVIDENCE REVIEW Studies were identified via electronic searches of Ovid MEDLINE, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), and the Cochrane Central Register of Controlled Trials (CENTRAL) from database inception to May 12, 2021 (the MEDLINE search was updated on June 8, 2021). Bibliographies of retrieved articles were also reviewed through ClinicalTrials.gov, FDA documents, and the manufacturer's website. Search terms included HP Acthar, ACTH gel, repository corticotropin, and terms for specific diseases, such as multiple sclerosis, nephrotic syndrome, rheumatoid arthritis, and West syndrome (or spasms, infantile). The review included randomized clinical trials (RCTs), nonrandomized and single-arm clinical trials, and prospective cohort studies that compared corticotropin with an active comparator, placebo, or no treatment. Data were extracted by 1 reviewer and verified by a second. Disagreements were resolved through discussion. Studies were qualitatively synthesized by indication to summarize important design features and results. FINDINGS Of 1059 records screened, 203 full-text articles were assessed for eligibility. A total of 41 studies involving 2235 participants met inclusion criteria; of those, 11 involved infantile spasms, 10 involved multiple sclerosis (MS), 11 involved rheumatological conditions, 7 involved nephrotic syndrome, 1 involved ocular conditions, and 1 involved sarcoidosis. Overall, 19 studies either included a single arm or exclusively compared different corticotropin dosing strategies. The evidence was most robust for the treatment of infantile spasms and MS. The largest number of studies comparing corticotropin with an active agent (n = 4) or placebo (n = 5) pertained to MS, with almost all studies finding that corticotropin performed better than placebo but no different than corticosteroids. For the treatment of infantile spasms, 8 controlled studies were identified (6 were randomized); of those, only 1 small RCT found corticotropin to be significantly superior to corticosteroids. Studies of patients with other conditions (n = 20) frequently lacked a control group (n = 12), were placebo-controlled (n = 5), or exclusively examined different corticotropin dosing strategies (n = 2). Placebo-controlled RCTs of rheumatoid arthritis, ankylosing spondylitis, optic neuritis, systemic lupus erythematosus, and nephrotic syndrome were generally small and did not consistently demonstrate that corticotropin was superior to placebo. Blinded RCTs showed a similar or greater number of adverse effects with corticotropin relative to corticosteroids. CONCLUSIONS AND RELEVANCE In this scoping review, few RCTs supported the clinical benefit of corticotropin for most FDA-approved indications. Most RCTs found that corticotropin was not superior to corticosteroids for treating relapses of MS or infantile spasms.
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Affiliation(s)
- Kim A Tran
- College of Pharmacy, Oregon State University at Oregon Health & Science University, Portland
| | - Curtis Harrod
- Center for Evidence-based Policy, Oregon Health & Science University, Portland
| | | | - David M Cohen
- Division of Nephrology and Hypertension, Department of Medicine, Oregon Health & Science University, Portland
| | - Atul A Deodhar
- Division of Arthritis and Rheumatic Diseases, Department of Medicine, Oregon Health & Science University, Portland
| | - Daniel M Hartung
- College of Pharmacy, Oregon State University at Oregon Health & Science University, Portland
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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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Abstract
ABSTRACT Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that may affect every organ. The multiple pathogenic mechanisms and heterogeneous phenotypes of SLE present unique challenges in the management of this complex disease. This article discusses new SLE therapies from the last 10 years. We will address new information in the realms of lifestyle interventions, antimalarials, nonsteroidal anti-inflammatory drugs, glucocorticoids, immunosuppressive disease modifying antirheumatic drugs, biological therapies, and other modalities as they pertain to SLE.
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Poola N, Due B, Wright D, Brooks LR, Zaman F. Pharmacokinetics and Pharmacodynamics of Repository Corticotropin Injection Compared With Synthetic ACTH 1-24 Depot and Methylprednisolone in Healthy Subjects. Clin Pharmacol Drug Dev 2021; 11:502-515. [PMID: 34528408 PMCID: PMC9290342 DOI: 10.1002/cpdd.1020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/09/2021] [Indexed: 11/08/2022]
Abstract
Repository corticotropin injection (RCI; Acthar Gel) is a naturally sourced complex mixture of adrenocorticotropic hormone (ACTH) analogs and other pituitary peptides. This phase 1, single-center, open-label, randomized parallel study directly compared the pharmacokinetics and pharmacodynamics of RCI and synthetic ACTH1-24 depot. Methylprednisolone was included to estimate the steroidogenic exposure of RCI and synthetic ACTH1-24 depot when used to treat nephrotic syndrome. A total of 48 healthy subjects aged 18 to 50 years were randomly assigned 1:1:1 to RCI (80 IU subcutaneously twice weekly on study days 1 and 4), synthetic ACTH1-24 depot (1 mg subcutaneously twice weekly on study days 1 and 4), or methylprednisolone (32 mg orally once daily on study days 1 through 6). After 2 doses, RCI induced about 5-fold lower free cortisol exposure and an estimated 4-fold lower steroidogenic exposure than synthetic ACTH1-24 depot. The lower endogenous cortisol response of RCI was achieved despite higher observed mean plasma concentrations of N25-deamidated porcine ACTH1-39 (the pharmacokinetic marker for RCI) than of ACTH1-24 . The different pharmacodynamic properties demonstrated by RCI and synthetic ACTH1-24 depot in this study suggest that these products in the ACTH class are not interchangeable.
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Affiliation(s)
| | - Bryan Due
- Mallinckrodt Pharmaceuticals, Hampton, New Jersey, USA
| | - Dale Wright
- Mallinckrodt Pharmaceuticals, Hampton, New Jersey, USA
| | - Leah R Brooks
- Mallinckrodt Pharmaceuticals, Hampton, New Jersey, USA
| | - Fahima Zaman
- Mallinckrodt Pharmaceuticals, Hampton, New Jersey, USA
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Askanase AD, Wright D, Zhao E, Zhu J, Bilyk R, Furie RA. Post Hoc Biomarker Analyses from a Phase 4, Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial of Repository Corticotropin Injection (Acthar® Gel) for Persistently Active Systemic Lupus Erythematosus. Rheumatol Ther 2021; 8:1871-1886. [PMID: 34478124 PMCID: PMC8572274 DOI: 10.1007/s40744-021-00351-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 07/13/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION We conducted post hoc analyses of biomarker results from a multicenter, randomized, double-blind, placebo-controlled study of repository corticotropin injection (RCI; Acthar® Gel) in patients with persistently active systemic lupus erythematosus (SLE) despite treatment with moderate-dose glucocorticoids. METHODS Adults with active SLE and moderate to severe rash and/or arthritis were enrolled in the primary study. Patients had active SLE despite treatment with stable glucocorticoids, antimalarials, and nonsteroidal anti-inflammatory drugs and/or immunosuppressants. Patients were randomly assigned to 80 U of RCI or placebo subcutaneously every other day for 4 weeks and then twice weekly through week 24. Blood samples were analyzed for serum cytokines and complement proteins using enzyme-linked immunosorbent or Luminex assays and for circulating leukocytes using flow cytometry. Biomarker levels were reported as percentages of the baseline and were further evaluated in subgroups stratified by baseline SLE Disease Activity Index-2000 (SLEDAI-2K) scores (< 10 vs. ≥ 10), baseline anti-double-stranded DNA levels (< 15 IU/mL vs. ≥ 15 IU/mL), and BILAG-based Combined Lupus Assessment (BICLA) responses at week 20 and 24. RESULTS RCI treatment resulted in reduced levels of B cell-activating factor and interleukin-6 cytokines in all subgroups compared with placebo. RCI treatment also resulted in lower levels of CD19+ B cells and CD19+IgD-CD27-CD95+ atypical activated memory B cells than did placebo in the higher baseline disease activity subgroups and in BICLA non-responders. Furthermore, RCI treatment led to greater increases in complement component (C)3 and C4 levels than did placebo in the higher baseline disease activity subgroups and in BICLA responders. CONCLUSIONS RCI may reduce inflammation through B cell immunomodulation in patients with persistently active SLE, particularly in those with higher disease activity. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT02953821.
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Affiliation(s)
- Anca D Askanase
- Columbia University Medical Center, 630 West 168th Street, P&S 3-3450, New York, NY, 10032, USA.
| | - Dale Wright
- Mallinckrodt Pharmaceuticals, Hampton, NJ, USA
| | - Enxu Zhao
- Mallinckrodt Pharmaceuticals, Hampton, NJ, USA
| | - Julie Zhu
- Mallinckrodt Pharmaceuticals, Hampton, NJ, USA
| | - Roman Bilyk
- Mallinckrodt Pharmaceuticals, Hampton, NJ, USA
| | - Richard A Furie
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Lobo-Chan AM, MacIntosh P, Bhat P. Publication bias, Open-Labeled Trials and Sky Rocketing Costs- Past, Present and Future of Repository Corticotropin Injection? Ocul Immunol Inflamm 2021; 30:1505-1507. [PMID: 34242098 DOI: 10.1080/09273948.2021.1884888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Repository corticotropin injection (RCI) has recently gained attention in the field of ocular inflammatory disease. Data supporting the use of RCI therapy in ocular inflammation are limited to case reports or small series subject to publication bias toward positive results. How this therapy differs significantly from oral corticosteroids, which are significantly cheaper, is unknown. Clinical trials to investigate the efficacy of RCI are currently limited to open-labeled non-comparative studies. Side effects of RCI are not insignificant, have been reported in other fields of medicine, and require further scrutiny. Finally, the price of RCI has skyrocketed with average yearly cost of therapy estimated to be between $480,000-$850,000 with allegations of the RCI manufacturing drug company providing remuneration to induce healthcare providers to prescribe RCIs but without any repercussions from a regulatory standpoint. The significant cost of RCI combined with lack of evidence-based guidance on efficacy, safety, and indications for use in ocular inflammation warrant caution in utilizing this therapy.
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Affiliation(s)
- Ann-Marie Lobo-Chan
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, USA
| | - Peter MacIntosh
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, USA
| | - Pooja Bhat
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, USA
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15
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Strand V, Simon LS, Meara AS, Touma Z. Measurement properties of selected patient-reported outcome measures for use in randomised controlled trials in patients with systemic lupus erythematosus: a systematic review. Lupus Sci Med 2021; 7:7/1/e000373. [PMID: 32591423 PMCID: PMC7319706 DOI: 10.1136/lupus-2019-000373] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 04/17/2020] [Accepted: 05/24/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The heterogeneous multisystem manifestations of SLE include fatigue, pain, depression, sleep disturbance and cognitive dysfunction, and underscore the importance of a multidimensional approach when assessing health-related quality of life. The US Food and Drug Administration has emphasised the importance of patient-reported outcomes (PROs) for approval of new medications and Outcome Measures in Rheumatology has mandated demonstration of appropriate measurement properties of selected PRO instruments. METHODS Published information regarding psychometric properties of the Medical Outcomes Survey Short Form 36 (SF-36), Lupus Quality of Life Questionnaire (LupusQoL) and Functional Assessment of Chronic Illness Therapy-Fatigue Scale (FACIT-F), and their suitability as end points in randomised controlled trials (RCTs) and longitudinal observational studies (LOS) were assessed. A search of English-language literature using MEDLINE and EMBASE identified studies related to development and validation of these instruments. Evidence addressed content validity, reliability (internal consistency and test-retest reliability), construct validity (convergent and divergent) and longitudinal responsiveness, including thresholds of meaning and discrimination. RESULTS All instruments demonstrated strong internal consistency, reliability and appropriate face/content validity, indicating items within each instrument that measure the intended concept. SF-36 and LupusQoL demonstrated test-retest reliability; although not published with FACIT-F in SLE supported by evidence from other rheumatic diseases. All instruments demonstrated convergent validity with other comparable PROs and responsivity to treatment. CONCLUSION The measurement properties of PRO instruments with published data from RCTs including: SF-36, LupusQoL and FACIT-F indicate their value as secondary end points to support labelling claims in RCTs and LOS evaluating the efficacy of SLE treatments.
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Affiliation(s)
- Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, Palo Alto, California, USA
| | | | | | - Zahi Touma
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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16
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Zhao T, Lin FA, Chen HP. Pattern of Nailfold Capillaroscopy in Patients With Systemic Lupus Erythematosus. Arch Rheumatol 2021; 35:568-574. [PMID: 33758813 PMCID: PMC7945704 DOI: 10.46497/archrheumatol.2020.7763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 12/02/2019] [Indexed: 11/30/2022] Open
Abstract
Objectives
This study aims to assess the nailfold capillary changes in patients with systemic lupus erythematosus (SLE), particularly among those with Raynaud’s phenomenon (RP), and the correlation between nailfold capillary changes and autoantibodies and disease activity. Patients and methods
A total of 85 patients (9 males, 76 females; median age 31 years; range, 15 to 58 years) with newly diagnosed SLE were selected between July 2016 and July 2018 from our hospital. Disease activity was scored by the SLE Disease Activity Index. Nailfold capillaroscopy (NFC) was performed in all patients. Results
Normal pattern, non-specific pattern, and scleroderma pattern were found in 13 (15.3%), 64 (75.3%), and eight (9.4%) patients, respectively. There was no significant difference between anti-double stranded deoxyribonucleic acid, anti-Smith antibodies, and low complements (all p>0.05), while significant differences of NFC pattern were found between low disease activity and high disease activity (p=0.002). RP was present in 31.7% of SLE patients, and the NFC findings in SLE patients with and without RP were significantly different in dilatation (81.5% vs. 14.0%). Conclusion The results of our study showed that capillary changes were very common in patients with SLE, which seem to associate with disease activity and RP condition.
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Affiliation(s)
- Ting Zhao
- Department of Rheumatology and Immunology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Fu-An Lin
- Department of Rheumatology and Immunology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hong-Pu Chen
- Department of Rheumatology and Immunology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
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17
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Patient-Reported Outcomes from a Phase 4, Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial of Repository Corticotropin Injection (Acthar ® Gel) for Persistently Active Systemic Lupus Erythematosus. Rheumatol Ther 2021; 8:573-584. [PMID: 33687687 PMCID: PMC7991053 DOI: 10.1007/s40744-021-00294-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/19/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction We assessed patient-reported outcomes from a multicenter, randomized, double-blind, placebo-controlled study of repository corticotropin injection (RCI; Acthar® Gel) in patients with persistently active systemic lupus erythematosus (SLE) despite treatment with moderate-dose glucocorticoids. Methods The trial enrolled adults with active SLE and moderate-to-severe rash and/or arthritis despite use of stable glucocorticoids (7.5 mg/day to 30 mg/day prednisone equivalent), antimalarials, and nonsteroidal anti-inflammatory drugs for ≥ 4 weeks and/or immunosuppressants for ≥ 8 weeks before screening. Patients were randomly assigned to 80 U of RCI or placebo subcutaneously every other day through week 4, then twice weekly through week 24. Primary analyses evaluated the change from baseline to week 24 in the Lupus Quality of Life (QoL) and Work Productivity and Activity Impairment (WPAI)-Lupus questionnaires. Post hoc analyses stratified results by baseline disease activity (SLE Disease Activity Index-2000 [SLEDAI-2K] < 10 or ≥ 10; Cutaneous Lupus Erythematosus Disease Area and Severity Index [CLASI]-Activity < 11 or ≥ 11; and British Isles Lupus Assessment Group [BILAG]-2004 < 20 or ≥ 20) and by BILAG-based Combined Lupus Assessment (BICLA) response at weeks 20 and 24. Results RCI treatment resulted in greater improvement in the LupusQoL pain domain at week 16 and planning domain at week 24 compared with placebo. Post hoc analyses demonstrated greater improvements with RCI in the pain, planning, and fatigue domains than with placebo at multiple time points in patients with higher disease activity by baseline SLEDAI-2K ≥ 10, CLASI-Activity ≥ 11, and BILAG-2004 ≥ 20 and/or in BICLA responders. Compared with placebo, RCI also resulted in greater improvements in percentage work time missed at week 24 in patients with baseline CLASI-Activity < 11 and in percentage impairment while working at week 16 in BICLA responders. Conclusions RCI may improve QoL and work productivity in patients who have persistently active SLE despite treatment with standard SLE therapy. Trial Registration ClinicalTrials.gov identifier NCT02953821. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-021-00294-z.
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18
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Wang X, Pham L, Poola N, Brooks LR, Due B. Comparison of Steroidogenic Exposure Following the Administration of Repository Corticotropin Injection With a Synthetic ACTH 1-24 Depot and Methylprednisolone in Healthy Subjects. Clin Pharmacol Drug Dev 2020; 10:777-788. [PMID: 33369276 PMCID: PMC8359281 DOI: 10.1002/cpdd.894] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/23/2020] [Indexed: 01/15/2023]
Abstract
The pharmacokinetics (PK) and pharmacodynamics (PD) of clinically relevant doses of repository corticotropin injection (Acthar Gel) and synthetic ACTH1‐24 depot have not been fully characterized. We compared the steroidogenic exposure of repository corticotropin injection and synthetic ACTH1‐24 depot in healthy adults at therapeutic doses using data from 2 separate phase 1 studies. Subjects were randomly assigned to repository corticotropin injection 40 or 80 IU subcutaneously twice weekly or 80 IU subcutaneously 3 times weekly for 15 days or to daily synthetic ACTH1‐24 depot doses of 0.5 mg subcutaneously, 0.75 mg subcutaneously, 1 mg subcutaneously, or 1 mg intramuscularly for 5 days. A population PK/PD model was developed to simulate the free cortisol exposure of a clinically relevant dose of synthetic ACTH1‐24 depot (1 mg subcutaneously twice weekly). Study drug doses were converted to methylprednisolone‐equivalent doses using the steroidogenic exposure of methylprednisolone 16 mg daily as a conversion factor. Doses were also converted to prednisone equivalents using a coefficient of 1.25. These analyses revealed that the steroidogenic exposure of repository corticotropin injection at clinically relevant doses was substantially lower than that for synthetic ACTH1‐24 depot. The 3 repository corticotropin injection regimens were equivalent to approximately 5, 8, and 16 mg of daily prednisone, respectively. On the basis of simulated free cortisol exposure, synthetic ACTH1‐24 depot 1 mg subcutaneously twice weekly was comparable to 57 mg of daily prednisone. These results suggest that repository corticotropin injection has pharmacological effects that cannot be considered identical to synthetic ACTH1‐24 depot.
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Affiliation(s)
- Xiaofeng Wang
- Mallinckrodt Pharmaceuticals, Bedminster, New Jersey, USA
| | - Loan Pham
- Mallinckrodt Pharmaceuticals, Bedminster, New Jersey, USA
| | - Nagaraju Poola
- Mallinckrodt Pharmaceuticals, Bedminster, New Jersey, USA
| | - Leah R Brooks
- Mallinckrodt Pharmaceuticals, Bedminster, New Jersey, USA
| | - Bryan Due
- Mallinckrodt Pharmaceuticals, Bedminster, New Jersey, USA
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19
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Askanase AD, Zhao E, Zhu J, Bilyk R, Furie RA. Repository Corticotropin Injection for Persistently Active Systemic Lupus Erythematosus: Results from a Phase 4, Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial. Rheumatol Ther 2020; 7:893-908. [PMID: 32996096 PMCID: PMC7695765 DOI: 10.1007/s40744-020-00236-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/14/2020] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION We assessed the efficacy and safety of repository corticotropin injection (RCI; Acthar® Gel) for persistently active systemic lupus erythematosus (SLE) despite use of moderate-dose glucocorticoids. METHODS This multicenter, double-blind, randomized, placebo-controlled study enrolled patients ≥ 18 years with active SLE and moderate to severe rash and/or arthritis despite stable glucocorticoid doses (7.5-30 mg/day prednisone equivalent) and antimalarials for ≥ 4 weeks and/or immunosuppressants for ≥ 8 weeks before screening. Stable glucocorticoid doses were required through week 16 with optional taper from weeks 16 to 24. Patients were randomized (1:1) to 80 U RCI subcutaneously or placebo every other day to week 4, then twice weekly to week 24. Endpoints included the proportion of SLE Responder Index (SRI)-4 responders at week 16; changes from baseline to week 16 in 28 Swollen Joint Count/Tender Joint Count (28 SJC/TJC) and Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI)-Activity score; and changes from baseline to week 24 in inflammatory cytokines. Safety was assessed by adverse events. RESULTS In the modified intention-to-treat population (RCI, n = 84; placebo, n = 85), the proportion of SRI-4 responders at week 16 was not significantly different between groups (RCI, 47.6%; placebo, 43.5%; OR [95% CI] 1.2 [0.6 to 2.2]; p = 0.5762). RCI treatment resulted in a reduction from baseline to week 16 in 28 SJC/TJC and CLASI-Activity score and from baseline to week 8 in a proliferation-inducing ligand cytokine. Post hoc analyses demonstrated a greater proportion of BILAG-based Combined Lupus Assessment responders for RCI than placebo at weeks 4, 12, and 20 and greater SRI-4 response in RCI-treated patients with baseline SLE Disease Activity Index-2000 ≥ 10 and CLASI-Activity ≥ 11. No new safety signals were identified. CONCLUSIONS Despite failure to achieve the primary endpoint, these results support the utility of RCI for treating persistently active SLE. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT02953821.
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Affiliation(s)
| | - Enxu Zhao
- Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA
| | - Julie Zhu
- Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA
| | - Roman Bilyk
- Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA
| | - Richard A Furie
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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20
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Saygin D, Oddis CV, Marder G, Moghadam-Kia S, Nandkumar P, Neiman N, Dzanko S, Koontz D, Aggarwal R. Follow-up results of myositis patients treated with H. P. Acthar gel. Rheumatology (Oxford) 2020; 59:2976-2981. [PMID: 32160301 DOI: 10.1093/rheumatology/keaa076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 01/20/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Idiopathic inflammatory myopathies (IIM) are a group of autoimmune diseases characterized by proximal muscle weakness. H. P. Acthar gel [repository corticotropin injection (RCI)] is a formulation of adrenocorticotropic hormone and has been approved by Food and Drug Administration for use in IIM; however, literature is limited. In this study, we report longitudinal follow-up of myositis patients treated with RCI. METHODS Patients with refractory IIM who were enrolled in the prospective, open-label RCI trial were included in this study. The post-trial follow-up period was 6 months with assessments every 2 months, which included myositis core set measures including extra-muscular global, muscle and patient global disease activities, HAQ, and manual muscle testing. RESULTS Two patients were lost to follow-up after finalization of the trial, and the remaining eight patients were enrolled in the follow-up study. One patient remained on RCI after the trial. In the follow-up period, four of eight patients had flare at on average 4.1 months after the RCI trial. Among the patients who flared, three required an increase in prednisone. One patient was restarted on RCI at 5.5 months, but had minimal improvement after 3 months. Four patients who remained stable continued to satisfy criteria for the definition of improvement through the 6-month follow-up. However, none showed any further improvement in the primary or secondary efficacy outcomes after the initial RCI trial. CONCLUSION To our knowledge, this is the first study reporting the follow-up results of patients treated with standard dose and duration of Acthar. We believe that our study will provide the basis for the development of future randomized RCI trials in IIM.
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Affiliation(s)
- Didem Saygin
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chester V Oddis
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Galina Marder
- Division of Rheumatology, Northwell Health, Formerly North Shore-Long Island Jewish Medical Center, Queens, NY, USA
| | - Siamak Moghadam-Kia
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Preeya Nandkumar
- Division of Rheumatology, Northwell Health, Formerly North Shore-Long Island Jewish Medical Center, Queens, NY, USA
| | | | - Sedin Dzanko
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Diane Koontz
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rohit Aggarwal
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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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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22
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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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23
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Hassan M, Karkhur S, Bae JH, Halim MS, Ormaechea MS, Onghanseng N, Nguyen NV, Afridi R, Sepah YJ, Do DV, Nguyen QD. New therapies in development for the management of non-infectious uveitis: A review. Clin Exp Ophthalmol 2020; 47:396-417. [PMID: 30938012 DOI: 10.1111/ceo.13511] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/16/2019] [Accepted: 03/24/2019] [Indexed: 02/06/2023]
Abstract
Uveitis is a spectrum of inflammatory disorders characterized by ocular inflammation and is one of the leading causes of preventable visual loss. The main aim of the treatment of uveitis is to control the inflammation, prevent recurrences of the disease and preserve vision while minimizing the adverse effects associated with the therapeutic agents. Initial management of uveitis relies heavily on the use of corticosteroids. However, monotherapy with high-dose corticosteroids is associated with side effects and cannot be maintained long term. Therefore, steroid-sparing agents are needed to decrease the burden of steroid therapy. Currently, the therapeutic approach for non-infectious uveitis (NIU) consists of a step-ladder strategy with the first-line option being corticosteroids in various formulations followed by the use of first-, second- and third-line agents in cases with suboptimal steroid response. Unfortunately, the agents currently at our disposal have limitations such as having a narrow therapeutic window along with their own individual potential side-effect profiles. Therefore, research has been targeted to identify newer drugs as well as new uses for older drugs that target specific pathways in the inflammatory response. Such efforts are made in order to provide targeted and safer therapy with reduced side effects and greater efficacy. Several specially designed molecular antibodies are currently in various phases of investigations that can potentially halt the inflammation in patients with NIU. In the review, we have provided a comprehensive overview of the current and upcoming therapeutic options for patients with NIU.
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Affiliation(s)
- Muhammad Hassan
- Byers Eye Institute, Stanford University, Palo Alto, California
| | - Samendra Karkhur
- Byers Eye Institute, Stanford University, Palo Alto, California.,Department of Ophthalmology, Sadguru Netra Chikitsalaya, Chitrakoot, India
| | - Jeong H Bae
- Byers Eye Institute, Stanford University, Palo Alto, California.,Department of Ophthalmology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | | | - Maria S Ormaechea
- Byers Eye Institute, Stanford University, Palo Alto, California.,Department of Ophthalmology, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Neil Onghanseng
- Byers Eye Institute, Stanford University, Palo Alto, California
| | - Nam V Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, California
| | - Rubbia Afridi
- Byers Eye Institute, Stanford University, Palo Alto, California
| | - Yasir J Sepah
- Byers Eye Institute, Stanford University, Palo Alto, California
| | - Diana V Do
- Byers Eye Institute, Stanford University, Palo Alto, California
| | - Quan D Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, California
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24
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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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25
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Extra-adrenal glucocorticoid biosynthesis: implications for autoimmune and inflammatory disorders. Genes Immun 2020; 21:150-168. [PMID: 32203088 PMCID: PMC7276297 DOI: 10.1038/s41435-020-0096-6] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 03/05/2020] [Accepted: 03/09/2020] [Indexed: 12/11/2022]
Abstract
Glucocorticoid synthesis is a complex, multistep process that starts with cholesterol being delivered to the inner membrane of mitochondria by StAR and StAR-related proteins. Here its side chain is cleaved by CYP11A1 producing pregnenolone. Pregnenolone is converted to cortisol by the enzymes 3-βHSD, CYP17A1, CYP21A2 and CYP11B1. Glucocorticoids play a critical role in the regulation of the immune system and exert their action through the glucocorticoid receptor (GR). Although corticosteroids are primarily produced in the adrenal gland, they can also be produced in a number of extra-adrenal tissue including the immune system, skin, brain, and intestine. Glucocorticoid production is regulated by ACTH, CRH, and cytokines such as IL-1, IL-6 and TNFα. The bioavailability of cortisol is also dependent on its interconversion to cortisone which is inactive, by 11βHSD1/2. Local and systemic glucocorticoid biosynthesis can be stimulated by ultraviolet B, explaining its immunosuppressive activity. In this review, we want to emphasize that dysregulation of extra-adrenal glucocorticoid production can play a key role in a variety of autoimmune diseases including multiple sclerosis (MS), lupus erythematosus (LE), rheumatoid arthritis (RA), and skin inflammatory disorders such as psoriasis and atopic dermatitis (AD). Further research on local glucocorticoid production and its bioavailability may open doors into new therapies for autoimmune diseases.
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Ho-Mahler N, Turner B, Eaddy M, Hanke ML, Nelson WW. Treatment with Repository Corticotropin Injection in Patients with Rheumatoid Arthritis, Systemic Lupus Erythematosus, and Dermatomyositis/Polymyositis. Open Access Rheumatol 2020; 12:21-28. [PMID: 32110122 PMCID: PMC7039080 DOI: 10.2147/oarrr.s231667] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 01/14/2020] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Repository corticotropin injection (RCI) is indicated for a number of autoimmune-mediated diseases including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and dermatomyositis (DM)/polymyositis (PM). To better understand the practice patterns and outcomes of RCI in patients with RA, SLE, or DM/PM, we conducted a retrospective medical record analysis. PATIENTS AND METHODS Participating providers selected deidentified medical records of patients meeting the inclusion criteria (age ≥18 years; physician-reported diagnosis of RA, SLE, or DM/PM; initiation of treatment with RCI between 1/1/2011 and 2/15/2016; ≥3 in-office visits with same site/provider). Collected data spanned 12 months before and after the first prescription date for RCI. Analyses included patient demographics and clinical history, RCI treatment patterns, and physician's impression of change. RESULTS Data from 54 patients with RA, 30 patients with SLE, and 8 patients with DM/PM were analyzed. The most frequently reported reasons for initiating RCI were lack of efficacy with prior treatment, acute exacerbation of disease, and use as add-on to ongoing therapy. The most common initial RCI dosing, 80 U twice weekly, was used for 84% of patients with RA, 75% with SLE, and 86% with DM/PM. The mean duration of treatment was 4.8, 6.5, and 6.8 months for RA, SLE, and DM/PM, respectively. Among the 57 patients with data on physician's impression of change with RCI, 78.1% of patients with RA, 94.7% with SLE, and 66.7% with DM/PM had a rating of "improved," and the mean time to best impression of change was 3.4, 4.3, and 3.4 months for RA, SLE, and DM/PM, respectively. CONCLUSION This study reports the real-world patient profile, use patterns, and outcomes of patients who used RCI for the treatment of RA, SLE, and DM/PM. These data can inform appropriate use and clinical expectations when using RCI.
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Affiliation(s)
| | | | | | - Mark L Hanke
- Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA
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Sharon Y, Chu DS. Adrenocorticotropic hormone gel for patients with non-infectious uveitis. Am J Ophthalmol Case Rep 2019; 15:100502. [PMID: 31297467 PMCID: PMC6598035 DOI: 10.1016/j.ajoc.2019.100502] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 01/23/2019] [Accepted: 06/20/2019] [Indexed: 11/21/2022] Open
Abstract
Purpose To describe the potential role of adrenocorticotropic hormone (ACTH) gel treatment in patients with chronic non-infectious uveitis. Observations We report the clinical course of three patients with bilateral, non-infectious anterior and intermediate uveitis, treated with ACTH gel for ≥12 months. All three patients had chronic and steroid-dependent ocular inflammation with subsequent development of ocular complications. Twice-weekly treatment with subcutaneous 80 unit/day ACTH gel was administered, and clinical outcome measures were observed. After a mean period of 14 months, all patients demonstrated significant improvement in disease activity, stable visual acuity, and an absence of side effects. Systemic steroids dosage was successfully reduced from a mean dose of 16 mg/day upon the initiation of ACTH gel treatment to 2 mg/day at last follow up. Conclusions and Importance Subcutaneous ACTH gel has shown to be a safe and effective therapy in the management of non-infectious uveitis. Specifically, ACTH gel plays a role in refractory and steroid-dependent cases and in those who do not respond to or are unable to tolerate other immunomodulatory therapies.
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Affiliation(s)
- Yael Sharon
- Metropolitan Eye Research and Surgery Institute, Palisades Park, NJ, USA
| | - David S Chu
- Metropolitan Eye Research and Surgery Institute, Palisades Park, NJ, USA.,Institute of Ophthalmology and Visual Science, New Jersey Medical School, Rutgers University, Newark, NJ, USA
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Bangert E, Wakani L, Merchant M, Strand V, Touma Z. Impact of belimumab on patient-reported outcomes in systemic lupus erythematosus: review of clinical studies. PATIENT-RELATED OUTCOME MEASURES 2019; 10:1-7. [PMID: 30666173 PMCID: PMC6330963 DOI: 10.2147/prom.s134326] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune, multisystem rheumatic disease with significant impact on health-related quality of life (HRQoL). Patient-reported outcomes (PROs) provide valuable data on patient perceptions across a variety of domains, such as HRQoL, pain, fatigue, and depression. The measurement and results of PROs with respect to HRQoL in randomized controlled trials (RCTs) on belimumab (B-lymphocyte stimulator inhibitor) in SLE are reviewed here, including BLISS-52 and BLISS-76, as well as publications related to belimumab trials that included HRQoL data. Other trials that evaluated belimumab did not include HRQoL data and were therefore not included in the analysis. The BLISS-52 and BLISS-76 RCTs met their primary endpoints and demonstrated improvements in PROs, measured by the 36-item Short Form Health Survey, EuroQol 5 Dimensions, and Functional Assessment of Chronic Illness Therapy-Fatigue Scale. Belimumab was shown overall to improve PROs in adult autoantibody-positive lupus patients.
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Affiliation(s)
- Elvira Bangert
- Division of Rheumatology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Laura Wakani
- University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto, ON, Canada,
| | - Mehveen Merchant
- Division of Rheumatology, Nova Scotia Health Authority, Dalhousie University, Halifax, NS, Canada
| | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, Palo Alto, CA, USA
| | - Zahi Touma
- University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto, ON, Canada,
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Elera-Fitzcarrald C, Fuentes A, González LA, Burgos PI, Alarcón GS, Ugarte-Gil MF. Factors affecting quality of life in patients with systemic lupus erythematosus: important considerations and potential interventions. Expert Rev Clin Immunol 2018; 14:915-931. [DOI: 10.1080/1744666x.2018.1529566] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Claudia Elera-Fitzcarrald
- Rheumatology Department, Hospital Guillermo Almenara Irigoyen, EsSalud, Lima, Perú
- Universidad Científica del Sur, Lima, Perú
| | - Alejandro Fuentes
- Departamento de Inmunología Clínica y Reumatología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis Alonso González
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, Medellín, Colombia
| | - Paula I. Burgos
- Departamento de Inmunología Clínica y Reumatología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Graciela S. Alarcón
- The University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Clinical Immunology and Rheumatology, Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Manuel F. Ugarte-Gil
- Rheumatology Department, Hospital Guillermo Almenara Irigoyen, EsSalud, Lima, Perú
- Universidad Científica del Sur, Lima, Perú
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Pham GS, Mathis KW. Lipopolysaccharide Challenge Reveals Hypothalamic-Pituitary-Adrenal Axis Dysfunction in Murine Systemic Lupus Erythematosus. Brain Sci 2018; 8:E184. [PMID: 30287776 PMCID: PMC6211064 DOI: 10.3390/brainsci8100184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 09/28/2018] [Accepted: 10/02/2018] [Indexed: 01/04/2023] Open
Abstract
Crosstalk between the brain and innate immune system may be dysregulated in systemic lupus erythematosus (SLE), a chronic autoimmune disease that presents with dysautonomia and aberrant inflammation. The hypothalamic-pituitary-adrenal (HPA) axis is an endogenous neuro-endocrine-immune pathway that can regulate inflammation following activation of vagal afferents. We hypothesized that chronic inflammatory processes in SLE are in part due to HPA axis dysfunction, at the level of either the afferent vagal-paraventricular nuclei (PVN) interface, the anterior pituitary, and/or at the adrenal glands. To study this, we challenged female control and SLE mice with lipopolysaccharide (LPS) and measured c-Fos expression as an index of neuronal activation, plasma adrenocorticotrophic hormone (ACTH) as an index of anterior pituitary function, and plasma corticosterone as an index of adrenal function. We found that c-Fos expression in the PVN, and plasma ACTH and corticosterone were comparable between unchallenged SLE and control mice. PVN c-Fos was increased similarly in control and SLE mice three hours after LPS challenge; however, there were no changes in plasma ACTH amongst any experimental groups post inflammatory challenge. Plasma corticosterone was markedly increased in LPS-challenged SLE mice compared to their vehicle-treated counterparts, but not in controls. Paradoxically, following LPS challenge, brain and spleen TNF-α were elevated in LPS-challenged SLE mice despite heightened plasma corticosterone. This suggests that, despite normal c-Fos expression in the PVN and activation of the HPA axis following LPS challenge, this cumulative response may not adequately defend SLE mice against inflammatory stimuli, leading to abnormally heightened innate immune responses and peripheral inflammation.
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Affiliation(s)
- Grace S Pham
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, TX 76107, USA.
| | - Keisa W Mathis
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, TX 76107, USA.
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Bonam SR, Wang F, Muller S. Autophagy: A new concept in autoimmunity regulation and a novel therapeutic option. J Autoimmun 2018; 94:16-32. [PMID: 30219390 DOI: 10.1016/j.jaut.2018.08.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 08/27/2018] [Accepted: 08/28/2018] [Indexed: 02/07/2023]
Abstract
Nowadays, pharmacologic treatments of autoinflammatory diseases are largely palliative rather than curative. Most of them result in non-specific immunosuppression, which can be associated with broad disruption of natural and induced immunity with significant and sometimes serious unwanted injuries. Among the novel strategies that are under development, tools that modulate the immune system to restore normal tolerance mechanisms are central. In these approaches, peptide therapeutics constitute a class of agents that display many physicochemical advantages. Within this class of potent drugs, the phosphopeptide P140 is very promising for treating patients with lupus, and likely also patients with other chronic inflammatory diseases. We discovered that P140 targets autophagy, a finely orchestrated catabolic process, involved in the regulation of inflammation and in the biology of immune cells. In vitro, P140 acts directly on a particular form of autophagy called chaperone-mediated autophagy, which seems to be hyperactivated in certain subsets of lymphocytes in lupus and in other autoinflammatory settings. In lupus, the "correcting" effect of P140 on autophagy results in a weaker signaling of autoreactive T cells, leading to a significant improvement of pathophysiological status of treated mice. These findings also demonstrated ex vivo in human cells, open novel avenues of therapeutic intervention in pathological conditions, in which specific and not general targeting is highly pursued in the context of the new action plans for personalized medicines.
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Affiliation(s)
- Srinivasa Reddy Bonam
- CNRS-University of Strasbourg, Biotechnology and Cell Signaling, Illkirch, France; CNRS-University of Strasbourg, Laboratory of Excellence Medalis, France
| | - Fengjuan Wang
- CNRS-University of Strasbourg, Biotechnology and Cell Signaling, Illkirch, France; CNRS-University of Strasbourg, Laboratory of Excellence Medalis, France
| | - Sylviane Muller
- CNRS-University of Strasbourg, Biotechnology and Cell Signaling, Illkirch, France; CNRS-University of Strasbourg, Laboratory of Excellence Medalis, France; University of Strasbourg Institute for Advanced Study, Strasbourg, France.
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Hartung DM, Johnston K, Cohen DM, Nguyen T, Deodhar A, Bourdette DN. Industry Payments to Physician Specialists Who Prescribe Repository Corticotropin. JAMA Netw Open 2018; 1:e180482. [PMID: 30646086 PMCID: PMC6324413 DOI: 10.1001/jamanetworkopen.2018.0482] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 03/30/2018] [Indexed: 12/22/2022] Open
Abstract
Importance Despite great expense and little evidence supporting use over corticosteroids, prescriptions for repository corticotropin (H. P. Acthar Gel; Mallinckrodt Pharmaceuticals) have increased markedly. Aggressive sales tactics and payments from the manufacturer may influence prescribing behavior for this expensive medication. Objective To characterize industry payments to physician specialists who prescribe corticotropin in the Medicare program. Design, Setting, and Participants This study was a cross-sectional analysis of Centers for Medicare & Medicaid Services 2015 Part D prescribing data linked to 2015 Open Payments data. Nephrologists, neurologists, and rheumatologists with more than 10 corticotropin prescriptions (frequent prescribers) in 2015 were included. Exposures Frequency, category, and magnitude of corticotropin-related payments from Mallinckrodt recorded in the Open Payments database. Main Outcomes and Measures Frequency, category, and magnitude of corticotropin-related payments from Mallinckrodt, as well as corticotropin prescriptions and expenditures for Medicare beneficiaries. Results Of the 235 included physicians, 65 were nephrologists; 59, neurologists; and 111, rheumatologists. A majority of frequent corticotropin prescribers (207 [88%]) received corticotropin-related payments from Mallinckrodt. The median (range) total payment for 2015 was $189 ($11-$138 321), with the highest payments ranging from $56 549 to $138 321 across the specialties. More than 20% of frequent prescribers received more than $10 000 and the top quartile of recipients received a median (range) of $33 190 ($9934-$138 321) in total payments per prescriber. Payments for compensation for services other than consulting contributed the most to the total amount. Mallinckrodt payments were positively associated with greater Medicare spending on corticotropin (β = 1.079; 95% CI, 1.044-1.115; P < .001), with every $10 000 in payments associated with a 7.9% increase (approximately $53 000) in Medicare spending on corticotropin. There was no association between corticotropin-related payments and spending on prescriptions for synthetic corticosteroids. Conclusions and Relevance In this study, most nephrologists, neurologists, and rheumatologists who frequently prescribe corticotropin received corticotropin-related payments from Mallinckrodt. These findings suggest that financial conflicts of interest may be driving use of corticotropin in the Medicare program.
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Affiliation(s)
- Daniel M. Hartung
- College of Pharmacy, Oregon State University, Corvallis
- Oregon Health & Science University, Portland
| | - Kirbee Johnston
- College of Pharmacy, Oregon State University, Corvallis
- Oregon Health & Science University, Portland
| | - David M. Cohen
- Division of Nephrology & Hypertension, Department of Medicine, Oregon Health & Science University, Portland
| | - Thuan Nguyen
- School of Public Health, Oregon Health & Science University, Portland
| | - Atul Deodhar
- Division of Arthritis & Rheumatic Diseases, Department of Medicine, Oregon Health & Science University, Portland
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Jácome Sánchez EC, García Castillo MA, González VP, Guillén López F, Correa Díaz EP. Coexistence of systemic lupus erythematosus and multiple sclerosis. A case report and literature review. Mult Scler J Exp Transl Clin 2018; 4:2055217318768330. [PMID: 29662683 PMCID: PMC5894926 DOI: 10.1177/2055217318768330] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 03/01/2018] [Accepted: 03/08/2018] [Indexed: 02/06/2023] Open
Abstract
Multiple sclerosis (MS) and systemic lupus erythematous (SLE) are autoimmune diseases, the coexistence of which is uncommon in patients. Owing to the rarity of this condition, the distinction between MS and SLE is a diagnostic challenge for neurologists. We present a case report in which MS and SLE were present in the same patient. There are few case reports in the world on the association between MS and SLE. The following case report is the first of its kind in which both MS and SLE are present in a patient from a country with low prevalence of MS such as Ecuador.
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Affiliation(s)
| | | | | | - Fernando Guillén López
- Department of Neurology, Hospital José Carrasco de Cuenca, Popayán y Pacto Andino, Ecuador
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Adrenocorticotropic hormone analogue as novel treatment regimen in ocular cicatricial pemphigoid. Am J Ophthalmol Case Rep 2018; 10:264-267. [PMID: 29780948 PMCID: PMC5956726 DOI: 10.1016/j.ajoc.2018.03.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 03/12/2018] [Accepted: 03/19/2018] [Indexed: 11/22/2022] Open
Abstract
Purpose To report the clinical outcome of a patient with ocular cicatricial pemphigoid, treated with adrenocorticotropic hormone gel. Observations A 75-year-old female with a biopsy proven ocular cicatricial pemphigoid (OCP) presented with bilateral conjunctival inflammation, fornix shortening, subepithelial fibrosis and corneal scarring. The patient was previously treated with topical steroids, topical cyclosporine and lubricating drops, and had undergone several amniotic membrane transplants due to recurrent corneal erosions. Once OCP diagnosis was established, the patient was started on oral corticosteroids (60 mg daily). In order to wean the patient off from systemic steroids, other immunomodulatory agents had been tried, including mycophenolate mofetil (1000 mg twice daily) and methotrexate (up to 25 mg weekly). However, none of these agents adequately controlled the ocular surface inflammation, and the patient experienced bilateral progressive cicatrization and corneal decompensation, as well as the development of side effects from the systemic corticosteroids, methotrexate and mycophenolate mofetil therapies. Treatment with twice weekly subcutaneous adrenocorticotropic hormone (ACTH) gel was initiated, along with tapering of systemic corticosteroids. During the 19 months treatment period, the patient demonstrated significant improvement in the ocular surface inflammation, visual acuity was stable and no significant adverse effects were observed. Systemic corticosteroids dosage was successfully reduced from 10 mg/day to none at last follow up. Conclusions and importance ACTH gel has shown to be an effective and safe treatment option for chronic, refractory and progressive ocular inflammatory disease. To the best of our knowledge, this is the first case report of a patient with OCP, treated successfully with ACTH gel. This case report may encourage ophthalmologists to employ ACTH gel in the management of OCP.
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Aggarwal R, Marder G, Koontz DC, Nandkumar P, Qi Z, Oddis CV. Efficacy and safety of adrenocorticotropic hormone gel in refractory dermatomyositis and polymyositis. Ann Rheum Dis 2017; 77:720-727. [DOI: 10.1136/annrheumdis-2017-212047] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 11/27/2017] [Accepted: 11/29/2017] [Indexed: 01/08/2023]
Abstract
AimTo evaluate the efficacy, safety, tolerability and steroid-sparing effect of repository corticotropin injection (RCI), in an open-label clinical trial, in refractory adult polymyositis (PM) and dermatomyositis (DM).MethodsAdults with refractory PM and DM were enrolled by two centres. Inclusion criteria included refractory disease defined as failing glucocorticoid and/or ≥1 immunosuppressive agent, as well as active disease defined as significant muscle weakness and >2 additional abnormal core set measures (CSMs) or a cutaneous 10 cm Visual Analogue Scale score of ≥3 cm and at least three other abnormal CSMs. All patients received RCI of 80 units subcutaneously twice weekly for 24 weeks. The primary end point for the trial was the International Myositis Assessment and Clinical Studies definition of improvement. Secondary end points included safety, tolerability, steroid-sparing as well as the 2016 American College of Rheumatology (ACR)/European League Against Rheumatism myositis response criteria (EULAR)ResultsTen of the 11 enrolled subjects (6 DM, 4 PM) completed the study. Seven of 10 met the primary end point of efficacy at a median of 8 weeks. There was a significant decrease in prednisone dose from baseline to conclusion (18.5 (15.7) vs 2.3 (3.2); P<0.01). Most individual CSMs improved at week 24 compared with the baseline, with the muscle strength improving by >10% and the physician global by >40%. RCI was considered safe and tolerable. No patient developed significant weight gain or an increase of haemoglobin A1c or cushingoid features.ConclusionTreatment with RCI was effective in 70% of patients, safe and tolerable, and led to a steroid dose reduction in patients with adult myositis refractory to glucocorticoid and traditional immunosuppressive drugs.Trial registration numberNCT01906372; Results.
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Wu B, Deshpande G, Gu T, Popelar B, Philbin M, Wan GJ. Demographics, treatment patterns, and healthcare utilization and cost of repository corticotropin injection in patients with systemic lupus erythematosus or rheumatoid arthritis. J Med Econ 2017; 20:1170-1177. [PMID: 28760047 DOI: 10.1080/13696998.2017.1362411] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate healthcare resource utilization (HRU) and costs among patients who initiated repository corticotropin injection (RCI; H.P. Acthar Gel) treatment for rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE). METHODS Patients aged ≥18 years with ≥2 diagnoses for either RA or SLE between July 1, 2006 and April 30, 2015 were identified in the HealthCore Integrated Research Database. Index RCI date was the earliest date of a medical or pharmacy claim for RCI after diagnosis. Baseline characteristics, pre- and post-initiation HRU and costs were assessed using descriptive statistics. RESULTS This study identified 180 RA patients (mean age = 60 years, 56% female) and 29 SLE patients (mean age = 45 years, 90% female) who initiated RCI. First RCI use averaged 7.1 and 22.6 months after the initial RA and SLE diagnosis, respectively. After RCI initiation, RA patients incurred significantly lower per-patient-per-month (PPPM) all-cause medical costs ($1,881 vs $682, p < .01) vs the pre-initiation period, driven by lower PPPM hospitalizations costs ($1,579 vs $503, p < .01). Overall PPPM healthcare costs were higher ($2,751 vs $5,487, p < .01) due to higher PPPM prescription costs ($869 vs $4,805, p < .01). Similarly, SLE patients had decreased PPPM hospitalization costs ($3,192 vs $799, p = .04) and increased PPPM prescription costs ($905 vs $7,443, p < .01) after initiating RCI; the difference in overall PPPM healthcare costs was not statistically significant likely, due to small sample size. CONCLUSION This study, across a heterogeneous population of variable disease duration, described clinical and healthcare utilization and costs of RA and SLE patients initiating RCI in a real-world setting. We observed that patients receiving RCI had lower utilization and costs for medical services in both disease populations, which partially offset the increased prescription costs by 30% and 37%. Future research is needed to explore factors associated with RCI initiation and its impact on long-term outcomes.
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Affiliation(s)
- Bingcao Wu
- a HealthCore, Inc. , Wilmington , DE , USA
| | | | - Tao Gu
- a HealthCore, Inc. , Wilmington , DE , USA
| | | | | | - George J Wan
- c Mallinckrodt Pharmaceuticals , Hampton , NJ , USA
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Myung G, Nelson WW, McMahon MA. Effects of Repository Corticotropin Injection on Medication Use in Patients With Rheumatologic Conditions: A Claims Data Study. J Pharm Technol 2017; 33:151-155. [PMID: 34861677 DOI: 10.1177/8755122517709825] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: Currently, specific studies identifying how repository corticotropin injection (RCI) is used in rheumatologic conditions are lacking. This is a first step to familiarize the trends of demographics using RCI as well as other medication use. Objective: RCI may produce anti-inflammatory as well as immune-modulatory effects. The purpose of this study is to examine the demographics of those who use RCI and the change in medication use, specifically prednisone, after RCI initiation. Method: This study used the Symphony Health Solutions (SHA) Claims database from 2008 to 2015. International Classification of Disease, Ninth Revision, codes were used to identify rheumatologic conditions including rheumatoid arthritis, systemic lupus erythematosus, dermatomyositis, and polymyositis. Information including RCI dose and concomitant medication uses was also obtained. Results: A total of 2749 patients with rheumatologic conditions receiving RCI were investigated for demographic information, and a total of 1048 patients with rheumatologic conditions on RCI were examined for medication use. The use of nonsteroidal anti-inflammatory drugs, disease-modifying anti-rheumatic drugs, and biologics overall decreased significantly in all 3 rheumatologic conditions except biologics in dermatomyositis/polymyositis. In addition, mean prednisone dose before and after RCI use significantly decreased one quarter (12 weeks) after RCI initiation. Conclusion: Claims-based study on RCI use indicates that RCI use might reduce use of prednisone, disease-modifying anti-rheumatic drugs, and other biologics. Further prospective study is needed.
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Philbin M, Niewoehner J, Wan GJ. Clinical and Economic Evaluation of Repository Corticotropin Injection: A Narrative Literature Review of Treatment Efficacy and Healthcare Resource Utilization for Seven Key Indications. Adv Ther 2017; 34:1775-1790. [PMID: 28660550 PMCID: PMC5565664 DOI: 10.1007/s12325-017-0569-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Repository corticotropin injection (RCI; H.P. Acthar® Gel; Mallinckrodt Pharmaceuticals Inc., Hampton, NJ) is a highly purified, prolonged-release porcine preparation of adrenocorticotropic hormone (ACTH) analogue that is FDA-approved for treatment of 19 autoimmune and inflammatory disorders. The diverse physiological actions of RCI at the melanocortin receptors (MCRs) affect processes involved in inflammation, pigmentation, steroidogenesis, and immunomodulation. Although RCI has been approved to treat inflammatory and autoimmune diseases for more than 60 years, recent progress in understanding both MCRs and the effects of RCI in modulating immune responses has led to increased interest in RCI as a therapeutic choice. The objective of this narrative literature review is to summarize key clinical and economic data on RCI treatment of seven disorders: infantile spasms (IS), multiple sclerosis (MS) relapses, proteinuria in nephrotic syndrome, rheumatoid arthritis (RA), dermatomyositis/polymyositis (DM/PM), systemic lupus erythematosus (SLE), and symptomatic sarcoidosis based on published literature and product information. An extended report is available as the Academy of Managed Care Pharmacy (AMCP) Formulary dossier for H.P. Acthar® Gel. METHODS Key studies of clinical efficacy and healthcare utilization and cost from 1956 to 2016 are summarized. RESULTS The evidence supports the efficacy of RCI across the seven indications. RCI is effective as a first-line therapy for IS. For the other six conditions, RCI may improve clinical outcomes during exacerbations or when the condition is resistant to conventional treatments. Use of RCI is associated with reduced use of biologics, corticosteroids, and disease-modifying antirheumatic drugs. Initiation of RCI therapy in patients with IS, MS, RA, SLE, or DM/PM has been associated with lower post-therapy healthcare utilization and medical costs, including decreases in hospitalizations, hospital length of stay, outpatient visits, and emergency department visits. CONCLUSION The evidence suggests that RCI may improve inflammatory and autoimmune disease control and patient quality of life, particularly in complex patients, and yield healthcare cost savings that demonstrate the medicine's value. FUNDING Mallinckrodt Pharmaceuticals Inc.
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Affiliation(s)
| | | | - George J Wan
- Mallinckrodt Pharmaceuticals Inc., Hampton, NJ, USA.
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Baughman RP, Sweiss N, Keijsers R, Birring SS, Shipley R, Saketkoo LA, Lower EE. Repository corticotropin for Chronic Pulmonary Sarcoidosis. Lung 2017; 195:313-322. [PMID: 28353116 PMCID: PMC5437201 DOI: 10.1007/s00408-017-9994-4] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/09/2017] [Indexed: 11/26/2022]
Abstract
Purpose The dose of repository corticotropin (RCI) and need for a loading dose in sarcoidosis patients receiving chronic corticosteroids are unclear. We performed a single-blind prospective study, comparing two doses of RCI in sarcoidosis. Methods Chronic pulmonary sarcoidosis patients receiving prednisone therapy with deterioration by 5% in FVC in the previous year were studied. RCI was administered subcutaneously at a loading dose of 80 units RCI for 10 days. Patients were randomized at day 14 to receive either 40- or 80-unit RCI twice a week. The dose of prednisone was modified by the clinician who was blinded to the patient’s dosage of RCI. Results Sixteen patients completed the full 24 weeks of the study. At week 24, there was a decrease in the dose of prednisone, and improvements in DLCO, King’s Sarcoidosis Questionnaire health status and fatigue score. There was no significant change in FVC % predicted. For the PET scan, there was a significant fall in the standard uptake value (SUV) of the lung lesions. Only 3/8 patients remained on 80 units RCI for full 24 weeks. There was no significant difference in the response to therapy for those treated with 40- versus 80-unit RCI. Conclusions Repository corticotropin treatment was prednisone-sparing and associated with significant improvement in DLCO, PET scan, and patient-reported outcome measures. A dose of 40-unit RCI twice a week was as effective as 80-unit RCI and was better tolerated.
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Affiliation(s)
- Robert P Baughman
- Department of Medicine, University of Cincinnati Medical Center, 1001 Holmes, Eden Ave, Cincinnati, OH, 45267, USA.
| | - Nadera Sweiss
- Department of Medicine, University of Illinois Chicago, Chicago, IL, USA
| | - Ruth Keijsers
- Department of Nuclear Medicine, St. Antonius Ziekenhuis Nieuwegein, Nieuwegein, The Netherlands
| | - Surinder S Birring
- Division of Asthma, Allergy and Lung Biology, King's College London, King's Health Partners, London, UK
| | - Ralph Shipley
- Department of Radiology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | | | - Elyse E Lower
- Department of Medicine, University of Cincinnati Medical Center, 1001 Holmes, Eden Ave, Cincinnati, OH, 45267, USA
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Shenavandeh S, Habibi S. Nailfold capillaroscopic changes in patients with systemic lupus erythematosus: correlations with disease activity, skin manifestation and nephritis. Lupus 2017; 26:959-966. [DOI: 10.1177/0961203316686702] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The clinical expression of systemic lupus erythematosus (SLE) is the consequence of endothelial cell damage leading to serious multiple organ dysfunction. The aim of this study was to assess the association between nailfold capillaroscopic changes and disease activity, skin and renal involvement in patients with SLE. Methods Demographic variables, clinical manifestations and laboratory data of 108 patients with SLE were investigated. Nailfold capillaroscopy (NFC) was performed in all patients. Result Morphological changes in NFC were observed in 102 out of 108 (94.4%) SLE patients. Minor changes were found in 33 (30.6%) and major changes in 69 (63.9%) cases. The disease activity was significantly higher in the patients with major changes ( p < 0.002). A higher incidence of microhaemorrhages was seen in patients with active SLE disease ( p < 0.04). In SLE patients with active skin involvement, the disturbed distribution ( p < 0.004) was more frequent and subtle changes ( p < 0.009) were less frequently observed as compared with patients without active skin involvement. In the group of SLE patients with renal involvement, no correlation was found between the capillary abnormalities and the presence of renal involvement ( p > 0.05), except for the elongated capillary loops, which were seen more often in patients with renal involvement than in patients without it ( p < 0.03). Conclusion The results of the study showed that capillary changes (abnormal capillaroscopy) were very common in patients with SLE, although there were no specific patterns like the ones in scleroderma patients, and some changes may be associated with disease activity, especially in patients with active skin involvement.
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Affiliation(s)
- S Shenavandeh
- Department of Internal Medicine, Division of Rheumatology, Shiraz University of Medical Sciences, Iran
| | - S Habibi
- School of Medicine, Fasa University of Medical Science, Fasa, Iran
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Ward F, Bargman JM. Membranous Lupus Nephritis: The Same, But Different. Am J Kidney Dis 2016; 68:954-966. [DOI: 10.1053/j.ajkd.2016.07.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 07/06/2016] [Indexed: 01/07/2023]
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Furie R, Mitrane M, Zhao E, Das M, Li D, Becker PM. Efficacy and tolerability of repository corticotropin injection in patients with persistently active SLE: results of a phase 4, randomised, controlled pilot study. Lupus Sci Med 2016; 3:e000180. [PMID: 27933199 PMCID: PMC5133412 DOI: 10.1136/lupus-2016-000180] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 09/14/2016] [Accepted: 09/24/2016] [Indexed: 12/02/2022]
Abstract
Objective To evaluate the efficacy of a prolonged-release formulation of a porcine adrenocorticotropic hormone analogue (repository corticotropin injection (RCI)) added to standard of care in patients requiring moderate-dose corticosteroids for symptomatic SLE. Methods This prospective, randomised, double-blind, phase 4, pilot study (NCT01753401) enrolled 38 patients with persistently active SLE involving skin and/or joints. Enrolled patients received RCI, 40 U daily or 80 U every other day, or volume-matched placebo gel, for 8 weeks, with dose tapering to twice weekly during weeks 5–8. Efficacy endpoints included proportion of responders at week 4 based on a novel composite measure that included resolution of rash or arthritis measured using the hybrid SLE Disease Activity Index (hSLEDAI) without worsening British Isles Lupus Assessment Group (BILAG) scores in other organ systems at week 4 (primary), as well as improvements in total hSLEDAI and BILAG scores and other measures of skin and joint disease activity over the 8-week treatment period. Results Response, as defined for the primary endpoint, did not differ significantly between the combined placebo and RCI-treated groups at week 4. At week 8, the proportion of responders was higher in RCI-treated patients but did not statistically differ between groups (RCI 40 U (53.8%), RCI 80 U (33.3%), combined placebo (27.3%)). However, RCI treatment was associated with statistically significant improvements in several secondary endpoints, including total hSLEDAI, total BILAG and Cutaneous Lupus Erythematosus Disease Area and Severity Index Activity scores within 8 weeks. Treatment was well tolerated. Conclusions Although the primary endpoint was not met in this pilot study, secondary and post hoc analyses suggested that RCI was associated with improvements in SLE disease activity in a select patient population with steroid-dependent persistent disease. Trial registration number NCT01753401; results.
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Affiliation(s)
- Richard Furie
- Hofstra Northwell School of Medicine, Northwell Health , Great Neck, New York , USA
| | | | - Enxu Zhao
- Research & Development, Mallinckrodt Pharmaceuticals Inc. , Ellicott City, Maryland , USA
| | - Maya Das
- Research & Development, Mallinckrodt Pharmaceuticals Inc. , Ellicott City, Maryland , USA
| | - Daner Li
- Research & Development, Mallinckrodt Pharmaceuticals Inc. , Ellicott City, Maryland , USA
| | - Patrice M Becker
- Research & Development, Mallinckrodt Pharmaceuticals Inc. , Ellicott City, Maryland , USA
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Agarwal A, Hassan M, Sepah YJ, Do DV, Nguyen QD. Subcutaneous repository corticotropin gel for non-infectious panuveitis: Reappraisal of an old pharmacologic agent. Am J Ophthalmol Case Rep 2016; 4:78-82. [PMID: 29503933 PMCID: PMC5757479 DOI: 10.1016/j.ajoc.2016.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 09/18/2016] [Accepted: 09/27/2016] [Indexed: 11/18/2022] Open
Abstract
Purpose To describe the clinical course of a patient with non-infectious idiopathic unilateral panuveitis and retinal vasculitis treated with subcutaneous repository adrenocorticotropic hormone (ACTH) gel. Observations A 33-year-old male presented with blurry vision and floaters in the left eye (OS). The best-corrected visual acuity was 20/20 in the right eye (OD) and 20/50 in OS at the time of initial presentation. Slit-lamp examination revealed mild anterior segment inflammation in OS. There were 1 + vitreous haze and 2 + cells noted in OS. Clinical examination and ancillary imaging assessment including fluorescein angiography revealed retinal vasculitis and optic nerve head inflammation. After infectious etiologies were ruled out, the patient was started on oral corticosteroids and enrolled in a clinical trial employing intravenous tocilizumab therapy. Six months after completion of the tocilizumab trial, the patient demonstrated recurrence of disease. Twice weekly subcutaneous ACTH gel was initiated and the patient demonstrated improvement of retinal vascular inflammation. Conclusions and importance Repository subcutaneous ACTH gel formulation may be a safe and viable therapeutic option for patients with non-infectious uveitis and retinal vasculitis. Clinical trials using this formulation in a larger patient cohort with longer monitoring are indicated to evaluate its tolerability and bioactivity.
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Affiliation(s)
- Aniruddha Agarwal
- Ocular Imaging Research and Reading Center (OIRRC), Omaha, NE, 68198-5540, USA
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Muhammad Hassan
- Ocular Imaging Research and Reading Center (OIRRC), Omaha, NE, 68198-5540, USA
| | - Yasir J. Sepah
- Ocular Imaging Research and Reading Center (OIRRC), Omaha, NE, 68198-5540, USA
| | - Diana V. Do
- Ocular Imaging Research and Reading Center (OIRRC), Omaha, NE, 68198-5540, USA
| | - Quan Dong Nguyen
- Ocular Imaging Research and Reading Center (OIRRC), Omaha, NE, 68198-5540, USA
- Corresponding author.
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Clemson CM, Yost J, Taylor AW. The Role of Alpha-MSH as a Modulator of Ocular Immunobiology Exemplifies Mechanistic Differences between Melanocortins and Steroids. Ocul Immunol Inflamm 2016; 25:179-189. [PMID: 26807874 PMCID: PMC5769144 DOI: 10.3109/09273948.2015.1092560] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Melanocortins are a highly conserved family of peptides and receptors that includes multiple proopiomelanocortin-derived peptides and five defined melanocortin receptors. The melanocortins have an important role in maintaining immune homeostasis and in suppressing inflammation. Within the healthy eye, the melanocortins have a central role in preventing inflammation and maintaining immune privilege. A central mediator of the anti-inflammatory activity is the non-steroidogenic melanocortin peptide alpha-melanocyte stimulating hormone. In this review we summarize the major findings of melanocortin regulation of ocular immunobiology with particular interest in the ability of melanocortin to induce immune tolerance and cytoprotection. The melanocortins have therapeutic potential because their mechanisms of action in regulating immunity are distinctly different from the actions of steroids.
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Affiliation(s)
- Christine M Clemson
- a Autoimmune and Rare Diseases , Mallinckrodt Pharmaceuticals , Hayward , CA , USA
| | - John Yost
- a Autoimmune and Rare Diseases , Mallinckrodt Pharmaceuticals , Hayward , CA , USA
| | - Andrew W Taylor
- b Department of Ophthalmology , Boston University School of Medicine , Boston , MA , USA
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Needham M, Mastaglia FL. Immunotherapies for Immune-Mediated Myopathies: A Current Perspective. Neurotherapeutics 2016; 13:132-46. [PMID: 26586486 PMCID: PMC4720681 DOI: 10.1007/s13311-015-0394-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Until recently, the treatment of immune-mediated inflammatory myopathies has largely been empirical with glucocorticoids, steroid-sparing immunosuppressive drugs, and intravenous immunoglobulin. However, a proportion of patients are only partially responsive to these therapies, and there has been a need to consider alternative treatment approaches. In particular, patients with inclusion body myositis are resistant to conventional immunotherapies or show only a transient response, and remain a major challenge. With increasing recognition of the different subtypes of immune-mediated inflammatory myopathies, and improved understanding of their pathogenesis, more targeted treatments are now being trialled. The overall approach to treatment, and novel therapies targeting B cells, T cells, and specific cytokines are discussed in this review.
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Affiliation(s)
- Merrilee Needham
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, 6150, WA, Australia.
- Fiona Stanley Hospital, Murdoch, 6150, WA, Australia.
- West Australian Neuroscience Research Institute, Queen Elizabeth II Medical Centre, Nedlands, 6009, WA, Australia.
| | - Frank L Mastaglia
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, 6150, WA, Australia
- West Australian Neuroscience Research Institute, Queen Elizabeth II Medical Centre, Nedlands, 6009, WA, Australia
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Baughman RP, Barney JB, O'Hare L, Lower EE. A retrospective pilot study examining the use of Acthar gel in sarcoidosis patients. Respir Med 2015; 110:66-72. [PMID: 26626451 DOI: 10.1016/j.rmed.2015.11.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 11/09/2015] [Accepted: 11/12/2015] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Acthar was reported as effective for the treatment of pulmonary sarcoidosis in the 1950s. Use of drug waned due to cost and toxicity compared to prednisone. Recent interest has reemerged as an alternative to high dose oral glucocorticoids. METHODS Chart review was performed on all advanced sarcoidosis patients seen at two centers who received at least one dose of Acthar gel therapy with at least six months of posttreatment follow up. In all cases prior sarcoidosis therapy and indications for use along with clinical outcome were noted. All patients initially received 80 IU intramuscular or subcutaneous administration twice a week. RESULTS A total of 47 patients were treated with Acthar gel therapy during the study period, and 18 (37%) discontinued drug within six months due to cost (four patients), death (two patients), or drug toxicity (eleven patients), or noncompliance (1 patient). Of the remaining 29 patients, eleven experienced objective improvement in one or more affected organs. All but two patients noted disease improvement or oral glucocorticoid reduction. Twenty-one patients were treated for more than six months (Median 274 days). Nineteen patients were on prednisone at time of starting Acthar gel: seventeen had their prednisone dosage reduced by more than fifty percent and one patient discontinued cyclophosphamide therapy. CONCLUSION In this group of advanced sarcoidosis patients, Acthar gel treatment for at least three months was associated with objective improvement in a third of patients. A third of patients were unable to take at least a three months of treatment.
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Affiliation(s)
| | | | - Lanier O'Hare
- University of Alabama Birmingham, Birmingham, AL, USA
| | - Elyse E Lower
- University of Cincinnati Medical Center, Cincinnati, OH, USA
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Zhou Y, Lower EE, Li H, Baughman RP. Sarcoidosis patient with lupus pernio and infliximab-induced myositis: Response to Acthar gel. Respir Med Case Rep 2015; 17:5-7. [PMID: 27222775 PMCID: PMC4821248 DOI: 10.1016/j.rmcr.2015.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 11/05/2015] [Accepted: 11/08/2015] [Indexed: 11/09/2022] Open
Abstract
Infliximab is an effective treatment for sarcoidosis patients with persistent disease despite glucocorticoids and immunosuppressive therapy. Patients receiving infliximab can experience side effects, inducing an autoimmune reaction. Treatment is unclear for sarcoidosis patients who develop autoimmune reactions to infliximab. We report a case of a patient with advanced sarcoidosis who developed a myositis type reaction to infliximab characterized by diffuse muscle achiness and weakness and marked elevations in serum creatinine phosphokinase (CPK) and aldolase. Manifestations of sarcoidosis and myositis improved after Acthar treatment. This is the first report of successful treatment with Acthar in a patient with advanced sarcoidosis with an autoimmune reaction to infliximab.
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Affiliation(s)
- Ying Zhou
- Department of Internal Medicine, University of Cincinnati Medical Center, 1001 Holmes, Eden Ave, Cincinnati, OH, 45267, USA; Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
| | - Elyse E Lower
- Department of Internal Medicine, University of Cincinnati Medical Center, 1001 Holmes, Eden Ave, Cincinnati, OH, 45267, USA
| | - Huiping Li
- Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
| | - Robert P Baughman
- Department of Internal Medicine, University of Cincinnati Medical Center, 1001 Holmes, Eden Ave, Cincinnati, OH, 45267, USA
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Olsen NJ, Decker DA, Higgins P, Becker PM, McAloose CA, Benko AL, Kovacs WJ. Direct effects of HP Acthar Gel on human B lymphocyte activation in vitro. Arthritis Res Ther 2015; 17:300. [PMID: 26507974 PMCID: PMC4624189 DOI: 10.1186/s13075-015-0823-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 10/13/2015] [Indexed: 12/30/2022] Open
Abstract
Introduction Both clinical experience and experimental evidence have suggested that Adrenocorticotropic hormone (ACTH) might directly exert immunomodulatory effects not dependent on adrenal steroidogenesis. Methods The direct effects of H.P. Acthar Gel® (Acthar), a repository preparation containing a porcine ACTH analogue, on human B lymphocyte function were studied in vitro using peripheral blood B cells isolated using anti-CD19 coated magnetic beads and activated by interleukin 4 (IL-4) and CD40 ligand (CD40L). Analysis of expression of messenger RNA (mRNA) encoding activation-induced cytidine deaminase (AICDA) was carried out by quantitative real-time polymerase chain reaction (PCR). Cellular proliferation was assessed by a flow cytometric technique using intracellular staining with carboxyfluorescein succinimidyl ester (CFSE). Immunoglobulin G (IgG) production was measured in cell supernatants using an immunoassay. Results Acthar was found to exert acute, dose-dependent inhibitory effects on IL-4/CD40L–mediated induction of the expression of activation-induced cytidine deaminase (AICDA) after 24 hours, as well as sustained inhibition of B cell proliferation and IgG production during five more days of culture, without deleterious effects on B cell viability. Conclusions These experiments demonstrate that Acthar can exert direct effects on the humoral immune system independent of any role in the regulation of adrenal steroidogenesis. Although the impact of these findings on clinical disease was not evaluated in this study, these data support the therapeutic potential of Acthar for the management of autoimmune diseases characterized by B cell activation and aberrant humoral immune function.
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Affiliation(s)
- Nancy J Olsen
- Division of Rheumatology, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, 17033, PA, USA.
| | - Dima A Decker
- Autoimmune and Rare Diseases Business, Mallinckrodt Pharmaceuticals, 6011 University Boulevard, Ellicott City, 21043, MD, USA.
| | - Paul Higgins
- Autoimmune and Rare Diseases Business, Mallinckrodt Pharmaceuticals, 6011 University Boulevard, Ellicott City, 21043, MD, USA.
| | - Patrice M Becker
- Autoimmune and Rare Diseases Business, Mallinckrodt Pharmaceuticals, 6011 University Boulevard, Ellicott City, 21043, MD, USA.
| | - Carl A McAloose
- Division of Rheumatology, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, 17033, PA, USA.
| | - Ann L Benko
- Division of Endocrinology, Diabetes, and Metabolism, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, PA, 17033, USA.
| | - William J Kovacs
- Division of Endocrinology, Diabetes, and Metabolism, The Pennsylvania State University, College of Medicine, 500 University Drive, Hershey, PA, 17033, USA.
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Li X, Golubovsky J, Hui-Yuen J, Shah U, Olech E, Lomeo R, Singh V, Busch H, Strandberg MJ, Strandberg K, Horowitz L, Askanase A. Adrenocorticotropic hormone gel in the treatment of systemic lupus erythematosus: A retrospective study of patients. F1000Res 2015; 4:1103. [PMID: 27158444 DOI: 10.12688/f1000research.7192.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2015] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES Acthar Gel is a long-acting formulation of adrenocorticotropic hormone (ACTH) with anti-inflammatory effects thought to be mediated in part through melanocortin receptor activation. This study was initiated to understand the role of Acthar Gel in SLE treatment in rheumatology practices. METHODS This is a retrospective case series of nine adult female patients treated with Acthar Gel for at least six months at five academic centers. Treating physicians completed a one-page questionnaire on lupus medications, disease activity, and outcomes. Clinical response was defined using SLEDAI 2K and improvement in the clinical manifestation(s) being treated. RESULTS The most common clinical SLE manifestations/indications requiring therapy with Acthar Gel were arthritis, rash, and inability to taper corticosteroids. The mean SLEDAI 2K score at baseline was 5.8 ± 5.0 (range 0-16). Six patients were concomitantly treated with corticosteroids (mean dose 18.3mg/day). All patients were on background SLE medications including immunosuppressives. Seven of nine patients had an overall improvement, with a decrease in SLEDAI 2K from 5.8 ± 5.0 at baseline to 3.5 ± 2.7 (range 0-8); four of five patients had improvement or resolution in arthritis, and one of two patients had resolution of inflammatory rash. Four patients discontinued corticosteroids and one patient tapered below 50% of the initial dose by 3 months of treatment with Acthar Gel. No adverse events were reported. CONCLUSIONS This study suggests a role for Acthar Gel as an alternative to corticosteroids in the treatment of SLE. Acthar Gel appears to be safe and well-tolerated after 6 months of treatment, with a significant reduction in disease activity.
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Affiliation(s)
- Xiao Li
- Division of Adult Rheumatology, Columbia University Medical Center, New York, NY, 10032, USA
| | - Josh Golubovsky
- Division of Adult Rheumatology, Columbia University Medical Center, New York, NY, 10032, USA
| | - Joyce Hui-Yuen
- Division of Pediatric Rheumatology, Columbia University Medical Center, New York, NY, 10032, USA
| | - Ummara Shah
- Division of Rheumatology, University of Rochester Medical Center, New York, NY, 14642, USA
| | - Ewa Olech
- University of Nevada School of Medicine, Las Vegas, NV, 89102, USA
| | - Rosalia Lomeo
- Arthritis and Pain Center, Mary Washington Hospital, Las Vegas, NV, 89102, USA
| | - Vijay Singh
- Arthritis Osteoporosis and Rheumatology Associates, Sewell, NJ, 08080, USA
| | - Howard Busch
- Family Arthritis Center, Jupiter, FL, 33458, USA
| | | | | | | | - Anca Askanase
- Division of Adult Rheumatology, Columbia University Medical Center, New York, NY, 10032, USA
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Li X, Golubovsky J, Hui-Yuen J, Shah U, Olech E, Lomeo R, Singh V, Busch H, Strandberg MJ, Strandberg K, Horowitz L, Askanase A. Adrenocorticotropic hormone gel in the treatment of systemic lupus erythematosus: A retrospective study of patients. F1000Res 2015; 4:1103. [PMID: 27158444 PMCID: PMC4850873 DOI: 10.12688/f1000research.7192.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2016] [Indexed: 12/13/2022] Open
Abstract
Objectives: Acthar Gel is a long-acting formulation of adrenocorticotropic hormone (ACTH) with anti-inflammatory effects thought to be mediated in part through melanocortin receptor activation. This study was initiated to understand the role of Acthar Gel in SLE treatment in rheumatology practices. Methods: This is a retrospective case series of nine adult female patients treated with Acthar Gel for at least six months at five academic centers. Treating physicians completed a one-page questionnaire on lupus medications, disease activity, and outcomes. Clinical response was defined using SLEDAI 2K and improvement in the clinical manifestation(s) being treated. Results: The most common clinical SLE manifestations/indications requiring therapy with Acthar Gel were arthritis, rash, and inability to taper corticosteroids. The mean SLEDAI 2K score at baseline was 5.8 ± 5.0 (range 0-16). Six patients were concomitantly treated with corticosteroids (mean dose 18.3mg/day). All patients were on background SLE medications including immunosuppressives. Seven of nine patients had an overall improvement, with a decrease in SLEDAI 2K from 5.8 ± 5.0 at baseline to 3.5 ± 2.7 (range 0-8); four of five patients had improvement or resolution in arthritis, and one of two patients had resolution of inflammatory rash. Four patients discontinued corticosteroids and one patient tapered below 50% of the initial dose by 3 months of treatment with Acthar Gel. No adverse events were reported. Conclusions: This study suggests a role for Acthar Gel as an alternative to corticosteroids in the treatment of SLE. Acthar Gel appears to be safe and well-tolerated after 6 months of treatment, with a significant reduction in disease activity.
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Affiliation(s)
- Xiao Li
- Division of Adult Rheumatology, Columbia University Medical Center, New York, NY, 10032, USA
| | - Josh Golubovsky
- Division of Adult Rheumatology, Columbia University Medical Center, New York, NY, 10032, USA
| | - Joyce Hui-Yuen
- Division of Pediatric Rheumatology, Columbia University Medical Center, New York, NY, 10032, USA
| | - Ummara Shah
- Division of Rheumatology, University of Rochester Medical Center, New York, NY, 14642, USA
| | - Ewa Olech
- University of Nevada School of Medicine, Las Vegas, NV, 89102, USA
| | - Rosalia Lomeo
- Arthritis and Pain Center, Mary Washington Hospital, Las Vegas, NV, 89102, USA
| | - Vijay Singh
- Arthritis Osteoporosis and Rheumatology Associates, Sewell, NJ, 08080, USA
| | - Howard Busch
- Family Arthritis Center, Jupiter, FL, 33458, USA
| | | | | | | | - Anca Askanase
- Division of Adult Rheumatology, Columbia University Medical Center, New York, NY, 10032, USA
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