ACTHAR (corticotropin)

ACTHAR (corticotropin)

OFFICE ADMINISTRATION

Indications for Prior Authorization:

• Acute exacerbations of multiple sclerosis (MS)
• Nephrotic syndrome
• Infantile spasms
• Stevens-Johnson syndrome
• Diagnostic testing: adrenocortical function
• Adjunctive therapy for short-term administration for an acute episode/exacerbation in psoriatic arthritis, rheumatoid arthritis, ankylosing spondylitis and acute/chronic allergic/inflammatory processes of the eye

Patients must meet the following criteria for the condition(s) above:

For All

• Must be given IM or SubQ only
• Patient must not have osteoporosis, congestive heart failure, hypertension, or systemic fungal infection

Acute exacerbation of MS

• Trial/failure or contraindication/allergic to IV Solu-Medrol or oral dexamethasone 140 mg

Nephrotic syndrome

• Prescribed by a nephrologist
• Patient has contraindication/intolerance to steroid therapy
• Patient does not have steroid resistance
• Patient has failed all standard therapies

Acute inflammatory uses

• Prescribed by specialist
• Patient has contraindication/intolerance to steroid therapy
• Patient does not have steroid resistance
• Patient patient has failed all standard therapies

The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee:

• Any other diagnosis not listed in the approved indications

Dosing:

Multiple Sclerosis, Acute

• Up to 120 units per day for three weeks maximum per exacerbation episode.  May repeat for 2-3 weeks (maximum 15 doses in 21 days)

Diagnostic testing, adrenocortical function

• Single injection of up to 80 units

Infantile Spasm

• Up to 75 units/m2 twice daily for 1 month

Nephrotic Syndrome

• 40-80 units IM/SubQ for one to three days

Inflammatory Use

• Up to 80 units per day for a maximum of one month

Approval:

The drug is approvable for one treatment cycle