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
Last review date: July 20, 2016