Version July 2025
Note: Indication-specific dosing is not provided in the manufacturer's labeling for most labeled uses. Individualize dosage and frequency based on the severity of the disease and the initial response of the patient. Sudden withdrawal may lead to adrenal insufficiency or recurrent symptoms; tapering the dose and increasing the injection interval prior to discontinuation may be necessary following prolonged administration.
Usual dosage range :
Note: Generally used as an adjunctive agent in patients whose disease is refractory to conventional treatments. Because maximal adrenal stimulation may not occur in the first few days of treatment, other therapies should be initiated when an immediate effect is needed.
IM, SUBQ: 40 to 80 units every 24 to 72 hours.
Indication-specific dosing:
Multiple sclerosis, acute exacerbation (alternative therapy):
Note: Treatment guidelines recommend the use of high dose IV or oral methylprednisolone for acute exacerbations of multiple sclerosis (Ref). Corticotropin may be an alternative therapy if IV corticosteroids cannot be administered or are not tolerated (Ref).
IM, SUBQ: 80 to 120 units/day for 2 to 3 weeks.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in manufacturer's labeling; use with caution.
There are no dosage adjustments provided in manufacturer's labeling; use with caution in cirrhosis.
Refer to adult dosing.
(For additional information see "Corticotropin injection gel: Pediatric drug information")
Dosage guidance:
Clinical considerations: Sudden withdrawal may lead to adrenal insufficiency or recurrent symptoms; tapering the dose prior to discontinuation of therapy may be necessary following prolonged administration.
Infantile spasms:
Note: Expert consensus guidelines based on currently available evidence show that corticotropin (ACTH) appears to be more effective than oral corticosteroids or vigabatrin (monotherapy) for the treatment of infantile spasms in most patients and is used most frequently for initial management of infantile spasms. For patients with tuberous sclerosis complex, corticotropin may be used for non-responders to vigabatrin therapy (Ref).
Although various dosing regimens (primarily high-dose and moderate/low-dose) have been described in the literature, an optimal dosing regimen has not been defined (Ref). With the high-dose regimen, initial efficacy response rates of 86% to 93% during the respective study periods have been reported (Ref); however, a randomized, comparative trial did not show the high-dose superior to low-dose ACTH; however, hypertension occurred more frequently in the high-dose group (Ref). Guidelines suggest consideration for low-dose ACTH regimens (as an alternative to high-dose); however, literature also suggests that the two dosing regimens are probably equally effective for short-term treatment (Ref). A US consensus report recommends short duration of high-dose (~2 weeks), followed by a taper (Ref). In clinical practice, high-dose ACTH is used more often by neurologists than low-dose protocols (Ref). In the US market, Acthar gel has FDA approval for treatment of infantile spasm in patients <2 years of age; however, trials may have been conducted with other corticotropin repository gel products in other countries.
Infants and Children <2 years:
High dose: Body-surface area (BSA) directed dosing: Vial: IM: 75 units/m2/dose twice daily or 150 units/m2/dose once daily for 2 weeks, followed by a 2-week taper: 30 units/m2/dose once daily in the morning for 3 days, followed by 15 units/m2/dose once daily in the morning for 3 days, followed by 10 units/m2/dose once daily in the morning for 3 days and 10 units/m2/dose every other morning for 6 days (Ref). In practice, some centers have used maximum doses of 80 units/dose twice daily or 160 units/dose once daily based on currently available dosage forms.
Low dose: Fixed dosing: Vial: IM: Initial: 20 units/day for 2 weeks; if patient responds, taper and discontinue over a 1-week period; if patient does not respond, increase dose to 30 units/day for 4 weeks then taper and discontinue over a 1-week period. Dosing based on a prospective, single-blind study which reported no major difference in effectiveness between high-dose long-duration versus low-dose short-duration ACTH therapy (Ref).
Anti-inflammatory or immunosuppressive:
Note: Although FDA approved, use has been replaced by other agents; most expert guidelines do not address corticotropin as a therapeutic option (Ref):
Children >2 years and Adolescents:
Fixed dosing: Acthar: Vial: IM, SUBQ: 40 to 80 units/dose every 24 to 72 hours (Ref).
Weight-directed dosing: Vial: IM: 0.8 units/kg/day or 25 units/m2/day divided every 12 to 24 hours (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in manufacturer's labeling; use with caution.
There are no dosage adjustments provided in manufacturer's labeling; use with caution in cirrhosis.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Reported adverse reactions are for infants and children for infantile spasms unless otherwise noted. Other adverse events associated with corticosteroids may also occur.
>10%:
Cardiovascular: Hypertension (11%)
Infection: Infection (20%)
Nervous system: Seizure (12%)
1% to 10%:
Cardiovascular: Cardiac abnormality (cardiac hypertrophy: 3%)
Endocrine & metabolic: Drug-induced Cushing's syndrome (3%), weight gain (1%)
Gastrointestinal: Decreased appetite (3%), diarrhea (3%), vomiting (3%)
Infection: Candidiasis (≥2%)
Nervous system: Irritability (7%)
Otic: Otitis media (≥2%)
Respiratory: Nasal congestion (1%), pneumonia (≥2%), upper respiratory tract infection (≥2%)
Miscellaneous: Fever (5%)
Frequency not defined (all indications and populations):
Dermatologic: Acne vulgaris, ecchymoses, hyperpigmentation, inadvertent suppression of skin test reaction
Endocrine & metabolic: Decreased serum calcium, decreased serum potassium, growth retardation, impaired glucose tolerance/prediabetes, negative nitrogen balance, pituitary insufficiency, secondary adrenocortical insufficiency, sodium retention
Gastrointestinal: Acute peptic ulcer with hemorrhage and perforation
Hematologic & oncologic: Petechia
Immunologic: Antibody development
Nervous system: Idiopathic intracranial hypertension
Neuromuscular & skeletal: Amyotrophy, aseptic necrosis of femoral head, aseptic necrosis of humeral head, osteoporosis, pathological fracture (long bones), steroid myopathy
Ophthalmic: Exophthalmos, glaucoma, increased intraocular pressure, subcapsular posterior cataract
Miscellaneous: Wound healing impairment
Postmarketing (all indications and populations):
Cardiovascular: Atrial fibrillation, heart failure, necrotizing angiitis, palpitations, shock, subdural hematoma
Dermatologic: Diaphoresis, epidermal thinning, facial erythema
Endocrine & metabolic: Fluid retention (including peripheral swelling), hirsutism, hypokalemic alkalosis, increased serum glucose, menstrual disease
Gastrointestinal: Abdominal distention, impaired intestinal carbohydrate absorption, nausea, pancreatitis, ulcerative esophagitis
Hypersensitivity: Anaphylactic shock, anaphylaxis, hypersensitivity reaction
Infection: Abscess
Local: Injection site reaction
Nervous stem: Dizziness, fatigue, headache, insomnia, intracranial hemorrhage, lethargy, malaise, myasthenia, reversible cerebral atrophy (usually secondary to hypertension), vertigo
Neuromuscular & skeletal: Asthenia, vertebral compression fracture
Hypersensitivity to proteins of porcine origin; patients with scleroderma, osteoporosis, systemic fungal infections, ocular herpes simplex, peptic ulcer disease, recent surgery, congestive heart failure, uncontrolled hypertension, primary adrenocortical insufficiency, adrenocortical hyperfunction; IV administration.
Acthar gel: Additional contraindications: Children <2 years of age with suspected congenital infections; coadministration of live or live attenuated vaccines.
Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Concerns related to adverse effects:
• Adrenal suppression: May cause hypercortisolism or suppression of hypothalamic-pituitary-adrenal (HPA) axis, particularly in younger children or in patients receiving high doses for prolonged periods. HPA axis suppression may lead to adrenal crisis. Withdrawal and discontinuation of a corticosteroid should be done slowly and carefully. Symptoms of adrenal insufficiency may be difficult to detect in infants treated for infantile spasms.
• Electrolyte disturbances: May increase retention of sodium and wasting of calcium and potassium; sodium restriction and/or potassium supplementation may be required.
• Hypersensitivity reactions: Antibodies may develop following prolonged use and increase the risk of hypersensitivity reactions.
• Immunosuppression: Prolonged use of corticosteroids may increase the incidence of secondary infection, mask acute infection (including fungal infections), prolong or exacerbate viral infections, or limit response to vaccines. Close observation is required in patients with tuberculosis (TB) infection (latent TB) and/or TB reactivity; if therapy is prolonged, prophylaxis should be started.
• Psychiatric disturbances: Corticosteroids may cause psychiatric disturbances, including depression, euphoria, insomnia, irritability (especially in infants), mood swings, personality changes, and psychotic manifestations; effects are reversible upon discontinuation of therapy. Preexisting psychiatric conditions (eg, emotional instability, psychotic tendencies) may be exacerbated by corticosteroid use.
Disease-related concerns:
• Cardiovascular disease: Use with caution in patients with hypertension; use has been associated with fluid retention and hypertension.
• Diabetes: Use with caution in patients with diabetes mellitus; may alter glucose production/regulation leading to hyperglycemia.
• Gastrointestinal disease: Use with caution in patients with GI disease (eg, diverticulitis, ulcerative colitis, risk of impending perforation, fresh intestinal anastomoses) or abscess/pyogenic infections due to risk of gastric ulcer, GI perforation, and GI bleeding.
• Hepatic impairment: Use with caution in patients with hepatic impairment, including cirrhosis; long-term use has been associated with fluid retention.
• Myasthenia gravis: Use with caution in patients with myasthenia gravis; exacerbation of symptoms has occurred, especially during initial treatment with corticosteroids.
• Ocular disease: Use with caution in patients with cataracts and/or glaucoma; increased intraocular pressure, open-angle glaucoma, and cataracts have occurred with prolonged corticosteroid use.
• Osteoporosis: Use with caution in patients of any age at risk for osteoporosis; high doses and/or long-term use of corticosteroids have been associated with increased bone loss and osteoporotic fractures.
• Renal impairment: Use with caution in patients with renal impairment; fluid retention may occur.
• Thyroid disease: Changes in thyroid status may necessitate dosage adjustments; metabolic clearance of corticosteroids increases in patients with hyperthyroidism and decreases in patients with hypothyroidism.
Special populations:
• Pediatric: May affect growth velocity.
Concurrent drug therapy issues:
• Vaccines: For Acthar gel, concomitant use of live or live attenuated vaccines is contraindicated; use caution with inactivated vaccines (response may be variable). For Purified Cortrophin gel, avoid vaccination against smallpox; use caution with other immunization procedures.
Other warnings/precautions:
• Discontinuation of therapy: Withdraw therapy with gradual tapering of dose.
Use with caution in patients with osteoporosis; underlying clinical condition may also impact bone health and osteoporotic effect of corticosteroids and corticotropin in pediatric patients (Leonard 2007). Corticosteroid use may cause psychiatric disturbances, including depression, euphoria, insomnia, mood swings, personality changes, and irritability (especially in infants).
Purified Cortrophin gel prefilled syringes (40 units/0.5 mL and 80 units/1 mL): FDA approved March 2025; current anticipated availability second quarter 2025.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Gel, Injection:
Acthar: 80 units/mL (5 mL) [contains phenol]
Cortrophin: 80 units/mL (1 mL, 5 mL) [contains phenol]
Pen-injector, Subcutaneous:
Acthar Gel: 40 units/0.5 mL (0.5 mL); 80 units/mL (1 mL) [contains phenol]
Prefilled Syringe, Subcutaneous:
Cortrophin Gel: 40 units/0.5 mL (0.5 mL); 80 units/mL (1 mL) [contains gelatin (pork), phenol]
No
Gel (Acthar Injection)
80 units/mL (per mL): $10,872.96
Gel (Cortrophin Injection)
80 units/mL (per mL): $8,905.00
Pen-injector (Acthar Gel Subcutaneous)
40 units/0.5 mL (per 0.5 mL): $5,436.60
80 units/mL (per mL): $10,872.90
Prefilled Syringe (Cortrophin Gel Subcutaneous)
40 units/0.5 mL (per 0.5 mL): $4,454.00
80 units/mL (per mL): $8,905.00
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution Reconstituted, Injection:
ACTH 40: 40 units ([DSC])
Acthar Gel is only available through specialty pharmacy distribution and not through traditional distribution sources (eg, wholesalers, retail pharmacies). Hospitals wishing to acquire Acthar Gel should contact FFF Enterprises (1-800-843-7477).
After treatment is initiated, discharge or outpatient prescriptions should be submitted to the Acthar Support and Access Program (A.S.A.P.) in order to ensure an uninterrupted supply of the medication. The Acthar Referral/Prescription form is available online at https://actharhcp.com/acthar-patient-support/supporting-patients-and-practices/#patient-support-tabs.
Additional information is available for the A.S.A.P. at https://actharhcp.com/acthar-patient-support/access-support/.
IM, SUBQ: Multidose vial: For IM or SUBQ use; do not administer IV. Warm gel to room temperature before administration. Do not over-pressurize vial prior to withdrawing product.
SUBQ:
Prefilled SelfJect injector (Acthar): For SUBQ administration only; use only to administer single doses of 40 units or 80 units. If other doses are needed, use multidose vial. Allow prefilled SelfJect injector to sit at room temperature for 45 minutes after removal from refrigerator. Do not use if solution is discolored, cloudy, or contains particulate matter. Administer into abdomen, back of arm, or upper thigh; rotate injection sites (do not use same site >1 time/week); avoid injecting within 1 inch of the navel, knee, or groin area. Avoid injecting into birthmarks, irritated skin, scars, stretch marks, tattoos, or warts. Also refer to product labeling for additional administration details.
Prefilled syringes (Purified Cortrophin): For SUBQ administration only. Allow prefilled syringes to sit at room temperature for 45 minutes after removal from refrigerator; do not use if solution appears solid at room temperature. Do not use if solution is discolored, cloudy, or contains particulate matter. Administer into abdomen (>2 inches from navel), upper thigh, or upper arm. Avoid injecting into scars, stretch marks, or areas of skin that are scaly, hard, swollen, irritated, inflamed, tender, or bruised. Also refer to product labeling for additional administration details.
Note: In pediatric patients, only corticotropin gel from multidose vials (Acthar Gel) should be used for doses and may be administered by trained parent/caregiver. The prefilled SelfJect injector is intended for self-administration of SUBQ doses in trained adults.
Parenteral: Acthar Gel: Warm gel before administration; do not over-pressurize vial when withdrawing dose volume. May be administered IM or SUBQ; route is dependent upon indication; do not administer IV.
Infantile spasms: Administer IM.
Anti-inflammatory or immunosuppressive: Administer IM or SUBQ.
An FDA-approved patient medication guide, which is available with the product information and as follows, must be dispensed with this medication:
Acthar Gel: https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/008372s071lbl.pdf
Atopic dermatitis (Purified Cortrophin): Treatment of atopic dermatitis.
Note: Although FDA approved for the treatment of atopic dermatitis, available data to support use in this condition are limited and use has been replaced by other agents. Current guidelines for the management of atopic dermatitis do not include recommendations for the use of corticotropin in the treatment of this condition (AAD [Sidbury 2014]).
Collagen diseases: Treatment of exacerbations or as maintenance therapy of systemic lupus erythematosus or systemic dermatomyositis (polymyositis).
Note: Although FDA approved for the treatment of collagen diseases, available data to support use in these conditions are limited and use has been replaced by other agents. Current guidelines for the treatment of systemic lupus erythematosus (EULAR [Fanouriakis 2019]) and recent guidance on the treatment of dermatomyositis and polymyositis (McGrath 2018; Yang 2019) and juvenile dermatomyositis (Bellutti Enders 2017) do not include recommendations for the use of corticotropin in the treatment of these conditions.
Dermatologic diseases: Treatment of severe erythema multiforme, severe psoriasis (Purified Cortrophin only), or Stevens-Johnson syndrome.
Note: Although FDA approved for the treatment of dermatologic diseases, available data to support use in these conditions are limited and use has been replaced by other agents. Current guidelines for the treatment of psoriasis (AAD/NPF [Menter 2020]) and Stevens-Johnson syndrome and toxic epidermal necrolysis (BAD [Creamer 2016]) and recent guidance on the treatment of erythema multiforme (Trayes 2019) do not include recommendations for the use of corticotropin in the treatment of these conditions.
Diuresis in nephrotic syndrome: To induce a diuresis or remission of proteinuria in patients with nephrotic syndrome without uremia of the idiopathic type or due to lupus erythematosus.
Note: Although FDA approved for diuresis in nephrotic syndrome, available data to support use in these conditions are limited and use has been replaced by other agents. Current guidelines for the treatment of lupus nephritis (EULAR/ERA-EDTA [Fanouriakis 2020]) and the management of glomerular diseases (KDIGO 2021) do not include recommendations for the use of corticotropin.
Infantile spasms (Acthar gel): Treatment of infantile spasms in infants and children younger than 2 years. Note: Corticotropin is the preferred treatment in most patients (AAN [Go 2012])
Multiple sclerosis: Treatment of acute exacerbations of multiple sclerosis in adults. Note: Treatment guidelines recommend the use of high dose IV or oral methylprednisolone for acute exacerbations of multiple sclerosis (AAN [Scott 2011]; NICE 2014). Corticotropin may be an alternative therapy if IV corticosteroids cannot be administered or are not tolerated (Simsarian 2011).
Ophthalmic diseases: Treatment of severe acute and chronic allergic and inflammatory processes involving the eye and its adnexa (eg, allergic conjunctivitis, keratitis, iritis, iridocyclitis, diffuse posterior uveitis, choroiditis, optic neuritis, chorioretinitis, anterior segment inflammation).
Note: Although FDA approved for the treatment of ophthalmic diseases, available data to support use in these conditions are limited.
Rheumatic disorders: As adjunctive therapy for acute episodes/exacerbations of psoriatic arthritis, rheumatoid arthritis, including juvenile rheumatoid arthritis (select cases may require low-dose maintenance therapy), acute gouty arthritis (Purified Cortrophin only), and/or ankylosing spondylitis.
Note: Although FDA approved for the treatment of rheumatic disorders, available data to support use in these conditions are limited and use has been replaced by other agents. Current guidelines for the treatment of psoriatic arthritis (ACR/NPF [Singh 2019]), rheumatoid arthritis (ACR [Fraenkel 2021]), juvenile idiopathic arthritis (ACR/AF [Ringold 2019]), gout (ACR [FitzGerald 2020]; EULAR [Richette 2017]), and ankylosing spondylitis (ACR/SAA/SRTN [Ward 2019]) do not include recommendations for the use of corticotropin in the treatment of these conditions.
Serum sickness: Treatment of serum sickness.
Note: Although FDA approved for the treatment of serum sickness, available data to support use in this condition are limited and use has been replaced by other agents. Available guidelines for the treatment of serum sickness do not include recommendations for the use of corticotropin (AAAAI/ACAAI 2010).
Sarcoidosis, pulmonary: Treatment of symptomatic sarcoidosis.
Note: Although FDA approved for symptomatic sarcoidosis, available data to support use in this condition are limited and use has been replaced by other agents. Current guidelines for the management of sarcoidosis suggest that corticotropin may be considered for patients in whom treatment with glucocorticoids and/or antimetabolites has failed (ERS [Baughman 2021]).
Corticotropin may be confused with corticorelin, cosyntropin
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Abrocitinib: Corticosteroids (Systemic) may increase immunosuppressive effects of Abrocitinib. Management: The use of abrocitinib in combination with other immunosuppressants is not recommended. Doses equivalent to more than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks are considered immunosuppressive. Risk D: Consider Therapy Modification
Acetylcholinesterase Inhibitors: Corticosteroids (Systemic) may increase adverse/toxic effects of Acetylcholinesterase Inhibitors. Increased muscular weakness may occur. Risk C: Monitor
Aldesleukin: Corticosteroids (Systemic) may decrease therapeutic effects of Aldesleukin. Risk X: Avoid
Amphotericin B: Corticosteroids (Systemic) may increase hypokalemic effects of Amphotericin B. Risk C: Monitor
Androgens: Corticosteroids (Systemic) may increase fluid-retaining effects of Androgens. Risk C: Monitor
Androgens: Hypertension-Associated Agents may increase hypertensive effects of Androgens. Risk C: Monitor
Antidiabetic Agents: Hyperglycemia-Associated Agents may decrease therapeutic effects of Antidiabetic Agents. Risk C: Monitor
Antithymocyte Globulin (Equine): Corticosteroids (Systemic) may increase adverse/toxic effects of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of systemic corticosteroid is reduced. Corticosteroids (Systemic) may increase immunosuppressive effects of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor
Baricitinib: Corticosteroids (Systemic) may increase immunosuppressive effects of Baricitinib. Management: The use of baricitinib in combination with potent immunosuppressants is not recommended. Doses equivalent to more than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks are considered immunosuppressive. Risk D: Consider Therapy Modification
BCG Products: Corticosteroids (Systemic) may decrease therapeutic effects of BCG Products. Corticosteroids (Systemic) may increase adverse/toxic effects of BCG Products. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Brincidofovir: Corticosteroids (Systemic) may decrease therapeutic effects of Brincidofovir. Risk C: Monitor
Brivudine: May increase adverse/toxic effects of Corticosteroids (Systemic). Risk X: Avoid
Calcitriol (Systemic): Corticosteroids (Systemic) may decrease therapeutic effects of Calcitriol (Systemic). Risk C: Monitor
CAR-T Cell Immunotherapy: Corticosteroids (Systemic) may decrease therapeutic effects of CAR-T Cell Immunotherapy. Corticosteroids (Systemic) may increase adverse/toxic effects of CAR-T Cell Immunotherapy. Specifically, the severity and duration of neurologic toxicities may be increased. Management: Avoid use of corticosteroids as premedication before treatment with CAR-T cell immunotherapy agents. Corticosteroids are indicated and may be required for treatment of toxicities such as cytokine release syndrome or neurologic toxicity. Risk D: Consider Therapy Modification
Cardiac Glycosides: Corticosteroids (Systemic) may increase adverse/toxic effects of Cardiac Glycosides. Risk C: Monitor
Chikungunya Vaccine (Live): Corticosteroids (Systemic) may increase adverse/toxic effects of Chikungunya Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may decrease therapeutic effects of Chikungunya Vaccine (Live). Risk X: Avoid
Cladribine: Corticosteroids (Systemic) may increase immunosuppressive effects of Cladribine. Risk X: Avoid
Coccidioides immitis Skin Test: Coadministration of Corticosteroids (Systemic) and Coccidioides immitis Skin Test may alter diagnostic results. Management: Consider discontinuing systemic corticosteroids (dosed at 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks) several weeks prior to coccidioides immitis skin antigen testing. Risk D: Consider Therapy Modification
Corticorelin: Corticosteroids (Systemic) may decrease therapeutic effects of Corticorelin. Specifically, the plasma ACTH response to corticorelin may be blunted by recent or current corticosteroid therapy. Risk C: Monitor
Cosyntropin: Coadministration of Corticosteroids (Systemic) and Cosyntropin may alter diagnostic results. Risk C: Monitor
COVID-19 Vaccine (Inactivated Virus): Corticosteroids (Systemic) may decrease therapeutic effects of COVID-19 Vaccine (Inactivated Virus). Risk C: Monitor
COVID-19 Vaccine (mRNA): Corticosteroids (Systemic) may decrease therapeutic effects of COVID-19 Vaccine (mRNA). Management: Give a 3-dose primary series for all patients aged 6 months and older taking immunosuppressive medications or therapies. Booster doses are recommended for certain age groups. See CDC guidance for details. Risk D: Consider Therapy Modification
COVID-19 Vaccine (Subunit): Corticosteroids (Systemic) may decrease therapeutic effects of COVID-19 Vaccine (Subunit). Risk C: Monitor
Deferasirox: Corticosteroids (Systemic) may increase adverse/toxic effects of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased. Risk C: Monitor
Dengue Tetravalent Vaccine (Live): Corticosteroids (Systemic) may decrease therapeutic effects of Dengue Tetravalent Vaccine (Live). Corticosteroids (Systemic) may increase adverse/toxic effects of Dengue Tetravalent Vaccine (Live). Specifically, the risk of vaccine associated infection may be increased. Risk X: Avoid
Denosumab: May increase immunosuppressive effects of Corticosteroids (Systemic). Management: Consider the risk of serious infections versus the potential benefits of coadministration of denosumab and systemic corticosteroids. If combined, monitor patients for signs/symptoms of serious infections. Risk D: Consider Therapy Modification
Desirudin: Corticosteroids (Systemic) may increase anticoagulant effects of Desirudin. More specifically, corticosteroids may increase hemorrhagic risk during desirudin treatment. Management: Discontinue treatment with systemic corticosteroids prior to desirudin initiation. If concomitant use cannot be avoided, monitor patients receiving these combinations closely for clinical and laboratory evidence of excessive anticoagulation. Risk D: Consider Therapy Modification
Desmopressin: Corticosteroids (Systemic) may increase hyponatremic effects of Desmopressin. Risk X: Avoid
Deucravacitinib: May increase immunosuppressive effects of Corticosteroids (Systemic). Management: The use of deucravacitinib in combination with potent immunosuppressants is not recommended. Doses equivalent to more than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks are considered immunosuppressive. Risk D: Consider Therapy Modification
Dinutuximab Beta: Corticosteroids (Systemic) may increase immunosuppressive effects of Dinutuximab Beta. Management: Corticosteroids are not recommended for 2 weeks prior to dinutuximab beta, during therapy and for 1 week after treatment. Doses equivalent to over 2 mg/kg or 20 mg/day of prednisone (persons over 10 kg) for 2 or more weeks are considered immunosuppressive Risk D: Consider Therapy Modification
Estrogen Derivatives: May increase serum concentration of Corticosteroids (Systemic). Risk C: Monitor
Etrasimod: Corticosteroids (Systemic) may increase immunosuppressive effects of Etrasimod. Risk C: Monitor
Filgotinib: Corticosteroids (Systemic) may increase immunosuppressive effects of Filgotinib. Management: Coadministration of filgotinib with systemic corticosteroids at doses equivalent to greater than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks is not recommended. Risk D: Consider Therapy Modification
Gallium Ga 68 Dotatate: Coadministration of Corticosteroids (Systemic) and Gallium Ga 68 Dotatate may alter diagnostic results. Risk C: Monitor
Growth Hormone Analogs: Corticosteroids (Systemic) may decrease therapeutic effects of Growth Hormone Analogs. Growth Hormone Analogs may decrease active metabolite exposure of Corticosteroids (Systemic). Risk C: Monitor
Hyaluronidase: Corticosteroids (Systemic) may decrease therapeutic effects of Hyaluronidase. Management: Patients receiving corticosteroids (particularly at larger doses) may not experience the desired clinical response to standard doses of hyaluronidase. Larger doses of hyaluronidase may be required. Risk D: Consider Therapy Modification
Immune Checkpoint Inhibitors (Anti-PD-1, -PD-L1, and -CTLA4 Therapies): Corticosteroids (Systemic) may decrease therapeutic effects of Immune Checkpoint Inhibitors (Anti-PD-1, -PD-L1, and -CTLA4 Therapies). Management: Carefully consider the need for corticosteroids, at doses of a prednisone-equivalent of 10 mg or more per day, during the initiation of immune checkpoint inhibitor therapy. Use of corticosteroids to treat immune related adverse events is still recommended Risk D: Consider Therapy Modification
Indium 111 Capromab Pendetide: Coadministration of Corticosteroids (Systemic) and Indium 111 Capromab Pendetide may alter diagnostic results. Risk X: Avoid
Inebilizumab: Corticosteroids (Systemic) may increase immunosuppressive effects of Inebilizumab. Risk C: Monitor
Influenza Virus Vaccines: Corticosteroids (Systemic) may decrease therapeutic effects of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiation of systemic corticosteroids at immunosuppressive doses. Influenza vaccines administered less than 14 days prior to or during such therapy should be repeated 3 months after therapy. Risk D: Consider Therapy Modification
Isoniazid: Corticosteroids (Systemic) may decrease serum concentration of Isoniazid. Risk C: Monitor
Leflunomide: Corticosteroids (Systemic) may increase immunosuppressive effects of Leflunomide. Management: Increase the frequency of chronic monitoring of platelet, white blood cell count, and hemoglobin or hematocrit to monthly, instead of every 6 to 8 weeks, if leflunomide is coadministered with immunosuppressive agents, such as systemic corticosteroids. Risk D: Consider Therapy Modification
Licorice: May increase serum concentration of Corticosteroids (Systemic). Risk C: Monitor
Loop Diuretics: Corticosteroids (Systemic) may increase hypokalemic effects of Loop Diuretics. Risk C: Monitor
Lutetium Lu 177 Dotatate: Corticosteroids (Systemic) may decrease therapeutic effects of Lutetium Lu 177 Dotatate. Management: Avoid repeated use of high-doses of corticosteroids during treatment with lutetium Lu 177 dotatate. Use of corticosteroids is still permitted for the treatment of neuroendocrine hormonal crisis. The effects of lower corticosteroid doses is unknown. Risk D: Consider Therapy Modification
Macimorelin: Coadministration of Corticosteroids (Systemic) and Macimorelin may alter diagnostic results. Risk X: Avoid
MetyraPONE: Coadministration of Corticosteroids (Systemic) and MetyraPONE may alter diagnostic results. Management: Consider alternatives to the use of the metyrapone test in patients taking systemic corticosteroids. Risk D: Consider Therapy Modification
Mifamurtide: Corticosteroids (Systemic) may decrease therapeutic effects of Mifamurtide. Risk X: Avoid
MiFEPRIStone: May decrease therapeutic effects of Corticosteroids (Systemic). MiFEPRIStone may increase serum concentration of Corticosteroids (Systemic). Management: Avoid mifepristone in patients who require long-term corticosteroid treatment of serious illnesses or conditions (eg, for immunosuppression following transplantation). Corticosteroid effects may be reduced by mifepristone treatment. Risk X: Avoid
Mumps- Rubella- or Varicella-Containing Live Vaccines: Corticosteroids (Systemic) may decrease therapeutic effects of Mumps- Rubella- or Varicella-Containing Live Vaccines. Corticosteroids (Systemic) may increase adverse/toxic effects of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Nadofaragene Firadenovec: Corticosteroids (Systemic) may increase adverse/toxic effects of Nadofaragene Firadenovec. Specifically, the risk of disseminated adenovirus infection may be increased. Risk X: Avoid
Natalizumab: Corticosteroids (Systemic) may increase immunosuppressive effects of Natalizumab. Risk X: Avoid
Neuromuscular-Blocking Agents (Nondepolarizing): May increase adverse neuromuscular effects of Corticosteroids (Systemic). Increased muscle weakness, possibly progressing to polyneuropathies and myopathies, may occur. Management: If concomitant therapy is required, use the lowest dose for the shortest duration to limit the risk of myopathy or neuropathy. Monitor for new onset or worsening muscle weakness, reduction or loss of deep tendon reflexes, and peripheral sensory decriments Risk D: Consider Therapy Modification
Nicorandil: Corticosteroids (Systemic) may increase adverse/toxic effects of Nicorandil. Gastrointestinal perforation has been reported in association with this combination. Risk C: Monitor
Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective): Corticosteroids (Systemic) may increase adverse/toxic effects of Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective). Risk C: Monitor
Nonsteroidal Anti-Inflammatory Agents (Nonselective): Corticosteroids (Systemic) may increase adverse/toxic effects of Nonsteroidal Anti-Inflammatory Agents (Nonselective). Risk C: Monitor
Nonsteroidal Anti-Inflammatory Agents (Topical): May increase adverse/toxic effects of Corticosteroids (Systemic). Specifically, the risk of gastrointestinal bleeding, ulceration, and perforation may be increased. Risk C: Monitor
Ocrelizumab: Corticosteroids (Systemic) may increase immunosuppressive effects of Ocrelizumab. Risk C: Monitor
Ofatumumab: Corticosteroids (Systemic) may increase immunosuppressive effects of Ofatumumab. Risk C: Monitor
Ozanimod: Corticosteroids (Systemic) may increase immunosuppressive effects of Ozanimod. Risk C: Monitor
Pidotimod: Corticosteroids (Systemic) may decrease therapeutic effects of Pidotimod. Risk C: Monitor
Pimecrolimus: May increase immunosuppressive effects of Corticosteroids (Systemic). Risk X: Avoid
Pneumococcal Vaccines: Corticosteroids (Systemic) may decrease therapeutic effects of Pneumococcal Vaccines. Risk C: Monitor
Poliovirus Vaccine (Live/Trivalent/Oral): Corticosteroids (Systemic) may decrease therapeutic effects of Poliovirus Vaccine (Live/Trivalent/Oral). Corticosteroids (Systemic) may increase adverse/toxic effects of Poliovirus Vaccine (Live/Trivalent/Oral). Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Polymethylmethacrylate: Corticosteroids (Systemic) may increase adverse/toxic effects of Polymethylmethacrylate. Specifically, the risk for hypersensitivity or implant clearance may be increased. Management: Use caution when considering use of bovine collagen-containing implants such as the polymethylmethacrylate-based Bellafill brand implant in patients who are receiving immunosuppressants. Consider use of additional skin tests prior to administration. Risk D: Consider Therapy Modification
Quinolones: Corticosteroids (Systemic) may increase adverse/toxic effects of Quinolones. Specifically, the risk of tendonitis and tendon rupture may be increased. Risk C: Monitor
Rabies Vaccine: Corticosteroids (Systemic) may decrease therapeutic effects of Rabies Vaccine. Management: Complete rabies vaccination at least 2 weeks before initiation of immunosuppressant therapy if possible. If combined, check for rabies antibody titers, and if vaccination is for post exposure prophylaxis, administer a 5th dose of the vaccine. Risk D: Consider Therapy Modification
Ritlecitinib: Corticosteroids (Systemic) may increase immunosuppressive effects of Ritlecitinib. Risk X: Avoid
Ritodrine: Corticosteroids (Systemic) may increase adverse/toxic effects of Ritodrine. Risk C: Monitor
Ruxolitinib (Topical): Corticosteroids (Systemic) may increase immunosuppressive effects of Ruxolitinib (Topical). Risk X: Avoid
Salicylates: May increase adverse/toxic effects of Corticosteroids (Systemic). These specifically include gastrointestinal ulceration and bleeding. Corticosteroids (Systemic) may decrease serum concentration of Salicylates. Withdrawal of corticosteroids may result in salicylate toxicity. Risk C: Monitor
Sargramostim: Corticosteroids (Systemic) may increase therapeutic effects of Sargramostim. Specifically, corticosteroids may enhance the myeloproliferative effects of sargramostim. Risk C: Monitor
Sipuleucel-T: Corticosteroids (Systemic) may decrease therapeutic effects of Sipuleucel-T. Management: Consider reducing the dose or discontinuing immunosuppressants, such as systemic corticosteroids, prior to initiating sipuleucel-T therapy. Doses equivalent to more than 2 mg/kg or 20 mg/day of prednisone given for 2 or more weeks are immunosuppressive. Risk D: Consider Therapy Modification
Sitafloxacin: Corticosteroids (Systemic) may increase adverse/toxic effects of Sitafloxacin. Specifically, the risk of tendonitis and tendon rupture may be increased. Management: Consider alternatives to coadministration of corticosteroids and sitafloxacin unless the benefits of coadministration outweigh the risk of tendon disorders. Risk D: Consider Therapy Modification
Sodium Benzoate: Corticosteroids (Systemic) may decrease therapeutic effects of Sodium Benzoate. Risk C: Monitor
Solriamfetol: May increase hypertensive effects of Hypertension-Associated Agents. Risk C: Monitor
Sphingosine 1-Phosphate (S1P) Receptor Modulators: May increase immunosuppressive effects of Corticosteroids (Systemic). Risk C: Monitor
Succinylcholine: Corticosteroids (Systemic) may increase neuromuscular-blocking effects of Succinylcholine. Risk C: Monitor
Tacrolimus (Systemic): Corticosteroids (Systemic) may decrease serum concentration of Tacrolimus (Systemic). Conversely, when discontinuing corticosteroid therapy, tacrolimus concentrations may increase. Risk C: Monitor
Tacrolimus (Topical): Corticosteroids (Systemic) may increase immunosuppressive effects of Tacrolimus (Topical). Risk X: Avoid
Talimogene Laherparepvec: Corticosteroids (Systemic) may increase adverse/toxic effects of Talimogene Laherparepvec. Specifically, the risk of infection from the live, attenuated herpes simplex virus contained in talimogene laherparepvec may be increased. Risk X: Avoid
Tertomotide: Corticosteroids (Systemic) may decrease therapeutic effects of Tertomotide. Risk X: Avoid
Thiazide and Thiazide-Like Diuretics: Corticosteroids (Systemic) may increase hypokalemic effects of Thiazide and Thiazide-Like Diuretics. Risk C: Monitor
Tofacitinib: Corticosteroids (Systemic) may increase immunosuppressive effects of Tofacitinib. Management: Coadministration of tofacitinib with potent immunosuppressants is not recommended. Doses equivalent to more than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks are considered immunosuppressive. Risk D: Consider Therapy Modification
Typhoid Vaccine: Corticosteroids (Systemic) may decrease therapeutic effects of Typhoid Vaccine. Corticosteroids (Systemic) may increase adverse/toxic effects of Typhoid Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Ublituximab: Corticosteroids (Systemic) may increase immunosuppressive effects of Ublituximab. Risk C: Monitor
Upadacitinib: Corticosteroids (Systemic) may increase immunosuppressive effects of Upadacitinib. Management: Coadministration of upadacitinib with systemic corticosteroids at doses equivalent to greater than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks is not recommended. Risk D: Consider Therapy Modification
Urea Cycle Disorder Agents: Corticosteroids (Systemic) may decrease therapeutic effects of Urea Cycle Disorder Agents. More specifically, Corticosteroids (Systemic) may increase protein catabolism and plasma ammonia concentrations, thereby increasing the doses of Urea Cycle Disorder Agents needed to maintain these concentrations in the target range. Risk C: Monitor
Vaccines (Live): Corticosteroids (Systemic) may increase adverse/toxic effects of Vaccines (Live). Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may decrease therapeutic effects of Vaccines (Live). Management: Avoid live vaccines during and for 1 month after therapy with immunosuppressive doses of corticosteroids (equivalent to prednisone > 2 mg/kg or 20 mg/day in persons over 10 kg for at least 2 weeks). Give live vaccines 4 weeks prior to therapy if possible. Risk D: Consider Therapy Modification
Vaccines (Non-Live/Inactivated/Non-Replicating): Corticosteroids (Systemic) may decrease therapeutic effects of Vaccines (Non-Live/Inactivated/Non-Replicating). Management: Administer vaccines at least 2 weeks prior to immunosuppressive corticosteroids if possible. If patients are vaccinated less than 14 days prior to or during such therapy, repeat vaccination at least 3 months after therapy if immunocompetence restored. Risk D: Consider Therapy Modification
Vitamin K Antagonists: Corticosteroids (Systemic) may increase anticoagulant effects of Vitamin K Antagonists. Risk C: Monitor
Yellow Fever Vaccine: Corticosteroids (Systemic) may increase adverse/toxic effects of Yellow Fever Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may decrease therapeutic effects of Yellow Fever Vaccine. Risk X: Avoid
Zoster Vaccine (Live/Attenuated): Corticosteroids (Systemic) may increase adverse/toxic effects of Zoster Vaccine (Live/Attenuated). Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may decrease therapeutic effects of Zoster Vaccine (Live/Attenuated). Risk X: Avoid
Endogenous corticotropin concentrations are increased near delivery (Smith 2007).
Corticotropin stimulates an endogenous steroid response; outcomes observed following systemic corticosteroid use during pregnancy may be relevant. Some studies have shown an association between first trimester systemic corticosteroid use and oral clefts; however, information is conflicting and may be influenced by maternal dose, duration/frequency of exposure, and indication for use. Additional data are needed to evaluate any potential risk of systemic corticosteroids and other adverse pregnancy outcomes (eg, gestational diabetes mellitus, low birth weight, preeclampsia, preterm birth) (ACOG 2019; Bandoli 2017; Lunghi 2010; Skuladottir 2014). Hypoadrenalism may occur in newborns following maternal use of corticosteroids in pregnancy; monitor.
It is not known if corticotropin is present in breast milk.
According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and the benefits of treatment to the mother.
May require increased dietary or supplemental intake of potassium; may require decreased dietary intake of sodium.
Blood pressure, cardiac function, weight; serum glucose, electrolytes; signs of adrenal insufficiency; signs of Cushing syndrome; secondary ocular infections.
Following prolonged use: Bone mass density, growth in children, signs and symptoms of infection, cataract formation.
Following discontinuation: Signs of infection, cardiac function, blood pressure, serum glucose, body weight, fecal blood.
Stimulates the adrenal cortex to secrete adrenal steroids (including cortisol), weakly androgenic substances, and aldosterone. Prolonged administration of large doses induces hyperplasia and hypertrophy of the adrenal cortex and continuous high output of cortisol, corticosterone, and weak androgens. Trophic effects on the adrenal cortex appear to be mediated by cyclic adenosine monophosphate. Also reported to bind to melanocortin receptors.
Onset: Maximum effect: Cortisol serum concentration: IM, SUBQ: 3 to 12 hours.
Duration of action: Repository: 10 to 25 hours, up to 3 days.
Absorption: IM: Over 8 to 16 hours.
Half-life elimination: ACTH: 15 minutes.
Excretion: Urine.
