Adrenocorticotropic hormone is used as a medication and as diagnostic agent in the ACTH stimulation test.[1][2]:316,1165[3]:84,271
The form that is purified from pig pituitary glands is known as corticotropin (INN, BAN)[1][2]:316 is a medication and naturally occurring polypeptide tropic hormone produced and secreted by the anterior pituitary gland.[3]:84
The form that is made synthetically is tetracosactide (INN), also known as tetracosactrin (BAN) and cosyntropin (USAN), and the acetate ester, tetracosactide acetate (JAN), also known as tetracosactrin acetate (BAN).[2]:1165[3]:271[4] It consists of the first 24 (of a total of 39) amino acids of ACTH and retains full function of the parent peptide.[2]:1165 Tetracosactide stimulates the release of corticosteroids such as cortisol from the adrenal glands, and is used for the ACTH stimulation test to assess adrenal gland function.[3]:271
Contents
1Medical uses
2Contraindications
3Adverse effects
4Pharmacology
5Chemistry
6Manufacturing
7History
8Society and culture
8.1Approved forms
8.2Doping
8.3Pricing
9Research
10Veterinary medicine
11See also
12References
13External links
Medical uses
Both corticotropin and tetracosactide have been used for diagnostic purposes to determine adrenocortical insufficiency, particularly in Addison's disease, via the ACTH stimulation test.[5][6][7] However, as of 2015 the US label for corticotropin does not include diagnostic use.[8]
Both corticotropin and tetracosactide have been used for therapeutic purposes.[8][9] In the US the tetracosactide label is limited to diagnosis[5][6] but the UK label provides for therapeutic uses.[9]
In the US corticotropin is used to treat epileptic spasms in infants, acute exacerbations of multiple sclerosis in adults; acute episodes of psoriatic arthritis and rheumatoid arthritis and ankylosing spondylitis; in acute exacerbations or as maintenance therapy for the collagen disorders like systemic lupus erythematosus and systemic dermatomyositis; for skin conditions like severe erythema multiforme and Stevens-Johnson syndrome; for serum sickness; for severe acute and chronic allergic and inflammatory processes involving the eye such as keratitis, iritis, iridocyclitis, diffuse posterior uveitis, choroiditis, optic neuritis, chorioretinitis, and anterior segment inflammation; sarcoidosis in the lungs; and to treat edema in certain nephrotic syndromes.[8]
In the UK tetracosactide is used for short-term therapy in conditions for which glucocorticoids are usually used but for some reason should not be; some uses include use for people who don't respond to glucocorticoids or cannot tolerate them who have ulcerative colitis, Crohn's disease, juvenile rheumatoid arthritis, rheumatoid arthritis, or osteoarthrosis.[9]
Contraindications
In the US the only contraindication for tetracosactide for diagnostic use is hypersensitivity to ADCH[6] but in the UK, regulators placed contraindications for hypersensitivity to ADCH and additionally, for people with allergic disorders including asthma, acute psychosis, infectious diseases, peptic ulcer, refractory heart failure, Cushing's syndrome, treatment of primary adrenocortical insufficiency and adrenocongenital syndrome.[7]
The same contraindications that were applied in the UK for diagnostic use of tetracosactide, apply for therapeutic use of both tetracosactide and corticotropin in the US and UK.[8][9]
In addition, the US label for corticotropin for therapeutic uses includes contraindications for people who have recently had surgery, and people with scleroderma, osteoporosis, uncontrolled hypertension, or sensitivity to proteins of porcine origin; in addition the infection diseases systemic fungal infection, ocular herpes simplex, and infants who have congenital infections are specified. The label also notes that people taking corticotropin for immunosuppression should not be given live vaccines.[8]
Adverse effects
People taking corticotropin or tetracosactide are more likely to get infections, and are at risk of hypothalamic-pituitary-axis (HPA) suppression and Cushing's syndrome.[8][9]
Pharmacology
In the normal situation, ACTH is released from the pituitary gland at the base of the brain. It acts on the adrenal glands to stimulate the production of steroid hormones (glucocorticoids). If the adrenal glands are healthy, a single injection of tetracosactide results in a rise in blood cortisol (hydrocortisone) concentrations in 30 minutes. If the adrenal glands appear not to be working then tetracosactide injection can be given to check whether the problem is due to diseased or damaged adrenals or due to lack of pituitary ACTH.
Tetracosactide stimulates the release of corticosteroids such as cortisol from the adrenal glands, and is used for the ACTH stimulation test to assess adrenal gland function.[3]:271
Chemistry
The synthetic form consists of the first 24 (of a total of 39) amino acids of ACTH and retains full function of the parent peptide.[2]:1165
Manufacturing
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History
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Society and culture
Approved forms
In the US, available forms of animal-derived corticotrophin have included:
Cortiocotrophin derived from pituitary glands from pigs, in a gel formulation as well as in a zinc hydrochloride formulation, each first approved in the US in 1955 and subsequently discontinued.[10][11] In September 2015 ANI Pharmaceuticals and Merck & Co. agreed that ANI would purchase NDA 009854 and NDA 008975 and related trademarks and other assets related to these two versions of corticotrophin from Merck for $75M and ongoing royalties; the transaction closed in January 2016.[12] As of November 2016 ANI was preparing its supplemental NDA to get approval to re-introduce this formulation;[13] in 2015 ANI estimated that the US market for these products was about $1 billion per year, based on sales of Acthar gel.[12]
Corticotrophin, first approved in 1952 and subsequently discontinued; as of January 2017 this NDA was under control of Parkedale, a subsidiary of King Pharmaceuticals which is in turn a subsidiary of Pfizer.[14][15]
Corticotrophin branded as "Acthar", was first approved in 1950 and was subsequently discontinued; as of January 2017 this NDA was under control of Sanofi.[16]
A corticotrophin was approved in 1957 under NDA 010831, was subsequently discontinued, and as of January 2017 was under control of Organics/Lagrange, a subsidiary of Abbvie via Abbott's acquisition of Solvay's drug business.[17][18][19] A generic version under this NDA was approved under ANDA 088772 and was subsequently discontinued, and as of January 2017 was under the control of Actavis.[20]
A corticotrophin called H.P. Acthar Gel was approved in 1952 and as of January 2017 was under the control of Mallinckrodt.[21] A repository version of H.P. Acthar gel was approved in 2010 and as of January 2017 was also under the control of Mallinkrodt.[22][8]
Synthetic forms were created as a replacement for the animal-derived products.[5]
In the US, available forms of tetracosactide/cosyntropin, the synthetic form of corticotrophin, have been approved only for diagnostic uses,[5] and have included:
A branded version called Cortrosyn, which was created and developed by Organon and was approved by the FDA in 1970, and as of January 2017 was under the control of Amphastar Pharmaceuticals,[23][24] and there were three generic versions under ANDAs, one for Mylan approved in 2009,[25] one for Sandoz/Novartis, approved in 2012,[26] and another for Amphastar under ANDA 016750.[23] This version is a powder that is reconstituted before use.[27][6]
A version of cosyntropin in solution (as opposed to powder) was developed by Sandoz/Novartis and was approved under the 505b(2) pathway in 2008; as of January 2017 it had been discontinued.[27][28][29]
In the UK, available forms of tetracosactide/cosyntropin, the synthetic form of corticotrophin, have been approved for both therapeutic and diagnostic uses, and have included:
A version branded Synacthen and provided in solution 250 mcg ampoules, for diagnostic uses, approved in 2008 and as of January 2017 controlled by Mallinckrodt.[7]
A version branded Synacthen, absorbed on to zinc phosphate, provided in milky white suspension, approved in 2008 and as of January 2017 controlled by Mallinckrodt.[9]
Doping
As of 2007, it was widely reported that tetracosactide had been used as an illegal performance-enhancing drug by professional cyclists.[30] It is known to be used as a doping agent to increase the secretion of glucocorticoids by adrenal glands.[31]
Pricing
Mallinckrodt acquired the rights to the animal-derived form via its acquisition of Questcor Pharmaceuticals in 2014.[32] When Questcor acquired the drug in 2001 it sold for $40 a vial; within a year of the acquisition Questcor raised the price of the drug to $1,500 per vial and to $28,000 by 2013.[33][34] In 2013, Questcor acquired the US rights to a competing product, Synacthen Depot, from Novartis.[34] In 2014 Mallinckrodt raised the price of Acthar further to $34,000.[35][36] The Federal Trade Commission and attorneys general from five states sued Mallinckrodt for anti-competitive behavior with regard to the acquisition of Synacthen Depot and the monopolistic pricing of Acthar, and in January 2017 the company settled, agreeing to pay $100 million and to license Synacthen Depot to a competitor.[32] According to Kaiser Health News, Mallinckrodt responded by increasing its Congressional lobbying to $610,000, and its contributions to Congress members to $44,000, in the first quarter of 2017.[37]
In Canada, Synacthen Depot's pricing increased by 2000% in 2015, causing some provincial single payer authorities to delist the drug from funded medications. The increase in the drug's price came after Mallinckrodt acquired Questcor and its drug portfolio, which included the worldwide rights to Synacthen Depot. Prior to the price increase, Mallinckrodt claims that the drug was manufactured at a loss. Some have claimed that the price increase is abusive.[38] The drug had been priced at $33 but rose to $680 per vial. As an off-patent pharmaceutical, a similar drug, differing in formulation, available in Europe, made by a different manufacturer, sells for $8 per vial.[39]
Research
Acthar gel has been proposed as a therapy to treat refractory autoimmune diseases[5] and refractory nephrotic syndrome due to a variety of glomerular diseases.[40]
Veterinary medicine
Both versions of the hormone are also used to perform the ACTH stimulation test to diagnose hypoadrenocorticism in dogs and sometimes cats.[41][42][43][44]
See also
Alsactide
Corticorelin
Metyrapone
Ludo Dierckxsens
References
^ abIndex Nominum 2000: International Drug Directory. Taylor & Francis. January 2000. pp. 275–. ISBN 978-3-88763-075-1.
^ abcdeJ. Elks (14 November 2014). The Dictionary of Drugs: Chemical Data: Chemical Data, Structures and Bibliographies. Springer. ISBN 978-1-4757-2085-3.
^ abcdeI.K. Morton; Judith M. Hall (6 December 2012). Concise Dictionary of Pharmacological Agents: Properties and Synonyms. Springer Science & Business Media. pp. 84–. ISBN 978-94-011-4439-1.
^Index Nominum 2000: International Drug Directory. Taylor & Francis. January 2000. pp. 1005–. ISBN 978-3-88763-075-1.
^ abcdeGettig J, Cummings JP, Matuszewski K (May 2009). "H.P. Acthar gel and cosyntropin review: clinical and financial implications". Pharmacy and Therapeutics. 34 (5): 250–7. PMC 2697107. PMID 19561871.
^ abc"Synacthen Ampoules 250 micrograms per ml - Summary of Product Characteristics" (First approved 25 June 1998 under PL 43357/0001). UK Electronic Medicines Compendium. June 8, 2016. Retrieved 23 January 2017.
^ abcdefg"US Label: H.P. Acthar Gel (repository corticotropin) and (corticotropin)" (First approved 1952). Mallinckrodt. February 2015.
^ abcdef"Synacthen Depot Ampoules 1mg/ml - Summary of Product Characteristics" (First approved 25 June 1998 under PL43357/0002). UK Electronic Medicines Compendium. June 8, 2016. Retrieved 23 January 2017.
^"NDA 009854: Purified corticotropin-zinc hydrochloride". FDA. Retrieved 22 January 2017.
^"NDA 008975: Purified corticotrophin gel". FDA. Retrieved 22 January 2017.
^ ab"Form 8K, Exhibit 99.1: Press release: ANI Pharmaceuticals to Acquire Two NDAs from Merck for $75 Million". ANI Pharmaceuticals via SEC Edgar. September 21, 2015. See Form 8-K, filed 2015-09-21, index page
^"Form 8-K Exhibit 99.1: ANI Pharmaceuticals Reports Record Third Quarter Results and Year-To-Date 2016 Highlights and Narrows Full-year Guidance". ANI Pharmaceuticals via SEC Edgar. November 3, 2016. See 8-K index page
^"NDA 008317: ACTH (Corticotropin)". FDA. Retrieved 22 January 2017.
^"King Pharmaceuticals, Inc. Form 10-K, Annual report for the fiscal year ended December 31, 2007". SEC Edgar.
^"NDA 007504: Acthar (Corticotropin)". FDA. Retrieved 22 January 2017.
^"NDA 010831: Corticotropin". FDA. Retrieved 22 January 2017.
^Whalen, Jeanne; Cimilluca, Dana; McCracken, Jeffrey (28 September 2009). "Abbott to Buy Solvay Drug Unit for $7 Billion". Wall Street Journal.
^"Press Release - Lincoln International". Lincoln International. 14 August 2013. Retrieved 23 January 2017.
^"ANDA 088772: Corticotropin". FDA. Retrieved 22 January 2017.
^"NDA 008372: H.P. Acthar Gel (Corticotropin)". FDA. Retrieved 22 January 2017.
^"NDA022432: H.P. Acthar Gel (Repository Corticotropin)". FDA. Retrieved 22 January 2017.
^ ab"NDA016750: Cortrosyn (Cosyntropin)". FDA. Retrieved 22 January 2017.
^Organon sold the rights to Cortrosyn to Amphastar in 2003, per "Amphastar Pharmaceuticals S-1, Amendment 5". SEC Edgar. October 27, 2005.
^"ANDA 090574: Cosyntropin". FDA. Retrieved 22 January 2017.
^"ANDA 202147:Cosyntropin". FDA. Retrieved 22 January 2017.
^ ab"NDA 022028: Summary review" (PDF). FDA. February 21, 2008.
^"NDA 022028: Cosyntropin solution". FDA. Retrieved 22 January 2017.
^"US Label: Cosyntropin Injection" (PDF). FDA. February 2008.
^Kimmage P (2007). "tour 87 stage 14". Rough Ride. Yellow Jersey Press. p. 125. ISBN 0-224-08017-2.
^Chaabo A, de Ceaurriz J, Buisson C, Tabet JC, Lasne F (February 2011). "Simultaneous quantification and qualification of synacthen in plasma". Anal Bioanal Chem. 399 (5): 1835–43. doi:10.1007/s00216-010-4565-z. PMID 21170520.
^ abJohnson, Carolyn Y. (January 18, 2017). "Maker of $34,000-a-vial drug to pay $100 million for allegedly preventing competition". Washington Post.
^Pollack A (2012-12-29). "Questcor Finds Profits, at $28,000 a Vial". New York Times.
^ abStaton, Tracy (June 18, 2015). "Questcor's Acthar maneuvers land Mallinckrodt in hot water with FTC, state AGs". FiercePharma.
^"Pharma corp. hikes infant epilepsy drug price by 2,000%, from $33.05 per vial to $680 per vial". Retrieved 16 November 2015.
^Galeon, Dom (21 January 2017). "Company Raises the Price of a Drug That Fights Infant Epilepsy by 85,000%". Futurism.
^Follow The Money: Drugmakers Deploy Political Cash As Prices And Anger Mount, By Jay Hancock and Elizabeth Lucas and Sydney Lupkin, Kaiser Health News, July 24, 2017
^Kelly Crowe (16 November 2015). "2,000% price hike for infant seizure drug called 'absurd'". CBC News.
^"Monday November 16th 2015". The National. CBC News. 16 November 2015.
^Bomback AS, Tumlin JA, Baranski J, Bourdeau JE, Besarab A, Appel AS, Radhakrishnan J, Appel GB (2011). "Treatment of nephrotic syndrome with adrenocorticotropic hormone (ACTH) gel". Drug Design, Development and Therapy. 5: 147–53. doi:10.2147/DDDT.S17521. PMC 3063118. PMID 21448451.
^Lathan, P; Moore, GE; Zambon, S; Scott-Moncrieff, JC (2008). "Use of a low-dose ACTH stimulation test for diagnosis of hypoadrenocorticism in dogs". Journal of Veterinary Internal Medicine. 22 (4): 1070–3. doi:10.1111/j.1939-1676.2008.0118.x. PMID 18537878.
^ACVIM, Ronald Lyman DVM Dipl. (November 1, 2008). "Consider ACTH stimulation test when you suspect canine hyperadrenocorticism". dvm360.com.
^"ACTH Stimulation Test" (PDF). Idexx. Archived from the original (PDF) on 2017-02-02. Retrieved 23 January 2017.
^Gallagher, Alex (November 2014). "Demystifying Tests for Hyperadrenocorticism" (PDF). Clinicians' Brief.
External links
Adrenocorticotropic+Hormone at the US National Library of Medicine Medical Subject Headings (MeSH)
Cosyntropin at the US National Library of Medicine Medical Subject Headings (MeSH)
v
t
e
Melanocortin receptor modulators
MC1
Agonists: ACTH (corticotropin)
Afamelanotide (melanotan I)
BMS-470539
Bremelanotide
HS-014
HS-024
MSH (α, β, γ)
Melanotan II
Modimelanotide
PL-8177
SHU-8914
SHU-9005
SHU-9119
SNAP-7941
Antagonists: ASIP
MC2
Agonists: ACTH (corticotropin)
Alsactide
Codactide
Giractide
Norleusactide (pentacosactride)
Seractide
Tetracosactide (tetracosactrin, cosyntropin)
Tosactide (octacosactrin)
Tricosactide
Tridecactide
MC3
Agonists: ACTH (corticotropin)
Afamelanotide (melanotan I)
Bremelanotide
MSH (α, β, γ)
Melanotan II
Modimelanotide
PG-931
Antagonists: AGRP
ASIP
HS-014
ML-00253764
PG-106
SHU-8914
SHU-9005
SHU-9119
MC4
Agonists: ACTH (corticotropin)
Afamelanotide (melanotan I)
AZD2820
BIM-22493
Bremelanotide
LY-2112688
MSH (α, β, γ)
Melanotan II
MK-0493
Modimelanotide
PF-00446687
PG-931
PL-6983
Ro 27-3225
Setmelanotide
THIQ
Antagonists: AGRP
ASIP
HS-014
HS-024
HS-131
JKC-363
MCL-0020
MCL-0042
MCL-0129
ML-00253764
MPB-10
SHU-8914
SHU-9005
SHU-9119
Unknown: Semax
MC5
Agonists: ACTH (corticotropin)
Afamelanotide (melanotan I)
Bremelanotide
HS-014
HS-024
MSH (α, β, γ)
Melanotan II
Modimelanotide
SHU-8914
SHU-9005
SHU-9119
Antagonists: ASIP
ML-00253764
Unknown: Semax
Unsorted
Agonists: Alsactide
Codactide
Giractide
Norleusactide (pentacosactride)
Seractide
Tetracosactide (tetracosactrin, cosyntropin)
Tosactide (octacosactrin)
Tricosactide
Tridecactide
Others
Propeptides: Lipotropin (β, γ)
N-POMC (NPP, pro-γ-MSH)
Proopiomelanocortin (POMC)
See also: Receptor/signaling modulators • Signaling peptide/protein receptor modulators
UpToDate Contents
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1. 副腎不全におけるACTHに対する反応の評価 evaluation of the response to acth in adrenal insufficiency
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3. 成人における副腎不全の診断 diagnosis of adrenal insufficiency in adults
Pitfalls in the interpretation of the cosyntropin stimulation test for the diagnosis of adrenal insufficiency.
Burgos N, Ghayee HK, Singh-Ospina N.
Current opinion in endocrinology, diabetes, and obesity. 2019 Jun;26(3)139-145.
Adrenal insufficiency is a rare disease characterized by cortisol deficiency. The evaluation of patients suspected of having adrenal insufficiency can be challenging because of the rarity of the disease and limitations in the biochemical assessment of the cortisol status by either basal or dynamic t
Low-protein diet decreased the adrenal function and spontaneous activity of mice during chronic heat stress.
Tsuda Y, Iwasawa K, Yamaguchi M.
Heliyon. 2019 Apr;5(4)e01463.
Protein restriction is a well-known risk factor that induces the deterioration of various biological functions. However, little is known about the effects of protein restriction on behavioral markers and the adrenal function of mice exposed to chronic stress. Here we evaluated the effects of a low-p
… They underwent the standard rapid ACTH test, consisting of measurement of plasma cortisol levels before and at 30 and 60 minutes after intravenous injection of 0.25 mg tetracosactide acetate (Cortrosyn <SUP>®</SUP>). …
… Pituitary-adrenocortical functions were studied in those patients who had been treated with adrenocortical steroids by means of insulin stress test, rapid ACTH test and ACTH Z (depo-tetracosactide) intramuscular injection test. …
英語タイトル：Global and Chinese Tetracosactide Industry, 2017 Market Research Report 商品コード：PROF7031937 発行会社（調査会社）：Prof Research 発行日：2017年3月7日 ページ数：150 レポート言語：英語 ...
New Zealand Data Sheet 1 SYNACTHEN ® tetracosactide hexaacetate 250 micrograms/mL solution for injection or infusion TRADE NAME SYNACTHEN i.m./i.v. ® 250 micrograms/mL solution for injection or infusion.
