Adrenocorticotropic hormone is used as a medication and as diagnostic agent in the

ACTH stimulation test The ACTH test (also called the cosyntropin, tetracosactide, or Synacthen test) is a medical test usually requested and interpreted by endocrinologists to assess the functioning of the adrenal glands' stress response by measuring the adrenal res ...

. The form that is purified from pig

pituitary gland The pituitary gland or hypophysis is an endocrine gland in vertebrates. In humans, the pituitary gland is located at the base of the human brain, brain, protruding off the bottom of the hypothalamus. The pituitary gland and the hypothalamus contr ...

s is known as corticotropin is a medication and naturally occurring

polypeptide Peptides are short chains of amino acids linked by peptide bonds. A polypeptide is a longer, continuous, unbranched peptide chain. Polypeptides that have a molecular mass of 10,000 Da or more are called proteins. Chains of fewer than twenty ...

tropic hormone produced and secreted by the

anterior pituitary gland The anterior pituitary (also called the adenohypophysis or pars anterior) is a major organ of the endocrine system. The anterior pituitary is the glandular, anterior lobe that together with the posterior pituitary (or neurohypophysis) makes up ...

. The form that is made synthetically is tetracosactide, also known as synacthen, tetracosactrin and cosyntropin. It consists of the first 24 (of a total of 39)

amino acid Amino acids are organic compounds that contain both amino and carboxylic acid functional groups. Although over 500 amino acids exist in nature, by far the most important are the 22 α-amino acids incorporated into proteins. Only these 22 a ...

s of ACTH and retains full function of the parent peptide. Tetracosactide stimulates the release of

corticosteroid Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are invo ...

s such as

cortisol Cortisol is a steroid hormone in the glucocorticoid class of hormones and a stress hormone. When used as medication, it is known as hydrocortisone. Cortisol is produced in many animals, mainly by the ''zona fasciculata'' of the adrenal corte ...

from the

adrenal gland The adrenal glands (also known as suprarenal glands) are endocrine glands that produce a variety of hormones including adrenaline and the steroids aldosterone and cortisol. They are found above the kidneys. Each gland has an outer adrenal corte ...

s, and is used for the

to assess

function.

Medical uses

Both corticotropin and tetracosactide have been used for diagnostic purposes to determine adrenocortical insufficiency, particularly in

Addison's disease Addison's disease, also known as primary adrenal insufficiency, is a rare long-term endocrine disorder characterized by inadequate production of the steroid hormones cortisol and aldosterone by the two outer layers of the cells of the adr ...

, via the

. However, as of 2015 the US label for corticotropin does not include diagnostic use. Both corticotropin and tetracosactide have been used for therapeutic purposes. In the US the tetracosactide label is limited to diagnosis but the UK label provides for therapeutic uses. In the US corticotropin is used to treat epileptic spasms in infants, acute exacerbations of

multiple sclerosis Multiple sclerosis (MS) is an autoimmune disease resulting in damage to myelinthe insulating covers of nerve cellsin the brain and spinal cord. As a demyelinating disease, MS disrupts the nervous system's ability to Action potential, transmit ...

in adults; acute episodes of

psoriatic arthritis Psoriatic arthritis (PsA) is a long-term inflammatory arthritis that may occur in some people affected by the autoimmune disease psoriasis. The classic features of psoriatic arthritis include dactylitis (sausage-like swelling of the fingers ...

and

rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects synovial joint, joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and h ...

and ankylosing spondylitis; in acute exacerbations or as maintenance therapy for collagen disorders like

systemic lupus erythematosus Lupus, formally called systemic lupus erythematosus (SLE), is an autoimmune disease in which the body's immune system mistakenly attacks healthy tissue in many parts of the body. Symptoms vary among people and may be mild to severe. Common ...

and systemic

dermatomyositis Dermatomyositis (DM) is a Chronic condition, long-term inflammatory disorder, inflammatory Autoimmune disease, autoimmune disorder which affects the skin and the muscles. Its symptoms are generally a skin rash and worsening muscle weakness over ...

; for skin conditions like severe erythema multiforme and Stevens–Johnson syndrome; for

serum sickness Serum sickness in humans is a adverse drug reaction, reaction to proteins in antiserum derived from a non-human animal source, occurring 5–10 days after exposure. Symptoms often include a rash, Arthralgia, joint pain, fever, and lymphadenopathy. ...

; for severe acute and chronic allergic and inflammatory processes involving the eye such as keratitis, iritis and iridocyclitis, diffuse posterior

uveitis Uveitis () is inflammation of the uvea, the pigmented layer of the eye between the inner retina and the outer fibrous layer composed of the sclera and cornea. The uvea consists of the middle layer of pigmented vascular structures of the eye and ...

, choroiditis,

optic neuritis Optic neuritis (ON) is a debilitating condition that is defined as inflammation of cranial nerve II which results in disruption of the neurologic pathways that allow visual sensory information received by the retina to be able to be transmitted to ...

, chorioretinitis, and anterior segment inflammation;

sarcoidosis Sarcoidosis (; also known as Besnier–Boeck–Schaumann disease) is a disease involving abnormal collections of White blood cell, inflammatory cells that form lumps known as granulomata. The disease usually begins in the lungs, skin, or lymph n ...

in the lungs; and to treat

edema Edema (American English), also spelled oedema (British English), and also known as fluid retention, swelling, dropsy and hydropsy, is the build-up of fluid in the body's tissue (biology), tissue. Most commonly, the legs or arms are affected. S ...

in certain

nephrotic syndrome Nephrotic syndrome is a collection of symptoms due to kidney damage. This includes proteinuria, protein in the urine, hypoalbuminemia, low blood albumin levels, hyperlipidemia, high blood lipids, and significant edema, swelling. Other symptoms ...

s. 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 do not respond to glucocorticoids or cannot tolerate them who have

ulcerative colitis Ulcerative colitis (UC) is one of the two types of inflammatory bowel disease (IBD), with the other type being Crohn's disease. It is a long-term condition that results in inflammation and ulcers of the colon and rectum. The primary sympto ...

Crohn's disease Crohn's disease is a type of inflammatory bowel disease (IBD) that may affect any segment of the gastrointestinal tract. Symptoms often include abdominal pain, diarrhea, fever, abdominal distension, and weight loss. Complications outside of the ...

, juvenile rheumatoid arthritis,

, or osteoarthrosis.

Contraindications

In the US the only contraindication for tetracosactide for diagnostic use is hypersensitivity to ACTH but in the UK, regulators placed contraindications for hypersensitivity to ACTH 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. 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. 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.

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.

Pharmacology

In the normal situation, ACTH is released from the

at the base of the brain. It acts on the adrenal glands to stimulate the production of steroid hormones (

glucocorticoid Glucocorticoids (or, less commonly, glucocorticosteroids) are a class of corticosteroids, which are a class of steroid hormones. Glucocorticoids are corticosteroids that bind to the glucocorticoid receptor that is present in almost every vertebra ...

s). If the adrenal glands are healthy, a single injection of tetracosactide results in a rise in blood

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

s such as

from the

s, and is used for the

to assess

function.

Chemistry

The synthetic form consists of the first 24 (of a total of 39)

s of ACTH and retains full function of the parent peptide.

Manufacturing

History

Society and culture

Approved forms

In the US, available forms of animal-derived corticotrophin have included: * Corticotrophin derived from

s 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. 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. Se
Form 8-K, filed 2015-09-21, index page
/ref> As of November 2016 ANI was preparing its supplemental NDA to get approval to re-introduce this formulation; in 2015 ANI estimated that the US market for these products was about $1 billion per year, based on sales of Acthar gel. * 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 Pfizer Inc. ( ) is an American Multinational corporation, multinational Pharmaceutical industry, pharmaceutical and biotechnology corporation headquartered at The Spiral (New York City), The Spiral in Manhattan, New York City. Founded in 184 ...

. * Corticotrophin branded as "Acthar", was first approved in 1950 and was subsequently discontinued; as of January 2017 this NDA was under control of

Sanofi Sanofi S.A. is a French Multinational corporation, multinational pharmaceutical and healthcare company headquartered in Paris, France. The corporation was established in 1973 and merged with Synthélabo in 1999 to form Sanofi-Synthélabo. In 200 ...

. * 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. 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 Actavis Generics (formerly known as Watson Pharmaceuticals and Actavis plc, prior to the acquisition of Irish-based Allergan, Inc.) is a global pharmaceutical company focused on acquiring, developing, manufacturing and marketing branded pharmaceut ...

. * A corticotrophin called H.P. Acthar Gel was approved in 1952 and as of January 2017 was under the control of

Mallinckrodt Mallinckrodt Pharmaceuticals plc is an American-Irish domiciled manufacturer of specialty pharmaceuticals (namely, adrenocorticotropic hormone), generic drugs and imaging agents. In 2017, it generated 90% of its sales from the U.S. healthcare s ...

. A repository version of H.P. Acthar gel was approved in 2010 and as of January 2017 was also under the control of Mallinkrodt. Synthetic forms were created as a replacement for the animal-derived products. In the US, available forms of tetracosactide/cosyntropin, the synthetic form of corticotrophin, have been approved only for diagnostic uses, and have included: *A branded version called Cortrosyn, which was created and developed by

Organon The ''Organon'' (, meaning "instrument, tool, organ") is the standard collection of Aristotle's six works on logical analysis and dialectic. The name ''Organon'' was given by Aristotle's followers, the Peripatetics, who maintained against the ...

and was approved by the FDA in 1970, and as of January 2017 was under the control of Amphastar Pharmaceuticals, and there were three generic versions under ANDAs, one for Mylan approved in 2009, one for Sandoz/

Novartis Novartis AG is a Swiss multinational corporation, multinational pharmaceutical company, pharmaceutical corporation based in Basel, Switzerland. Novartis is one of the largest pharmaceutical companies in the world and was the eighth largest by re ...

, approved in 2012, and another for Amphastar under ANDA 016750. This version is a powder that is reconstituted before use. * A version of cosyntropin in solution (as opposed to powder) was developed by Sandoz/

and was approved under the 505b(2) pathway in 2008; as of January 2017 it had been discontinued. 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. * 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.

Doping

As of 2007, it was widely reported that tetracosactide had been used as an illegal performance-enhancing drug by professional cyclists. It is known to be used as a doping agent to increase the secretion of glucocorticoids by adrenal glands.

Pricing

Mallinckrodt acquired the US rights to the animal-derived form via its acquisition of Questcor Pharmaceuticals in 2014. 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. In 2013, Questcor acquired the US rights to a competing product, Synacthen Depot, from Novartis. In 2014 Mallinckrodt raised the price of Acthar further to $34,000. The

Federal Trade Commission The Federal Trade Commission (FTC) is an independent agency of the United States government whose principal mission is the enforcement of civil (non-criminal) United States antitrust law, antitrust law and the promotion of consumer protection. It ...

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. 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. 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

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. 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.

Research

Acthar gel has been proposed as a therapy to treat refractory

autoimmune disease An autoimmune disease is a condition that results from an anomalous response of the adaptive immune system, wherein it mistakenly targets and attacks healthy, functioning parts of the body as if they were foreign organisms. It is estimated tha ...

s and refractory

due to a variety of glomerular diseases.

Veterinary medicine

Both versions of the hormone are also used to perform the

to diagnose hypoadrenocorticism in dogs and sometimes cats.

References

External links

* * {{Melanocortin receptor modulators Medical controversies Melanocortin receptor agonists Peptide therapeutics