Corticotropin (HP Acthar Gel)

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