Referral/Enrollment Form for H.P. Acthar Gel (repository corticotropin injection)

Your patients’ Acthar prescription is only available through specialty pharmacy distribution and cannot be filled at a retail pharmacy. To get the prescription and reimbursement process started, download, fill out, and fax in the referral form below, so the Acthar Support & Access Program (A.S.A.P.) can begin your request.

Download form

To avoid processing delays, please make sure:

To include phone numbers for your direct office contact and backup office contact
Provide clinical documentation and copies of detailed patient charts/notes

Since prior authorizations are common, a statement of medical necessity may be needed.

If you have any questions or need assistance filling out your form, contact A.S.A.P.

Phone: 1-888-435-2284
Fax: 1-877-937-2284
Monday to Friday, 8 AM to 8 PM ET.

A.S.A.P. will keep you and your patient informed about the delivery status of their Acthar prescription.

Indication

H.P. Acthar^® Gel (repository corticotropin injection) is indicated as monotherapy for the treatment of infantile spasms in infants and children under 2 years of age.

IMPORTANT SAFETY INFORMATION

Contraindications

Acthar should never be administered intravenously.
Administration of live or live attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of Acthar.
Acthar is contraindicated where congenital infections are suspected in infants.
Acthar is contraindicated in patients with scleroderma, osteoporosis, systemic fungal infections, ocular herpes simplex, recent surgery, history of or the presence of a peptic ulcer, congestive heart failure, uncontrolled hypertension, primary adrenocortical insufficiency, adrenocortical hyperfunction or sensitivity to proteins of porcine origins.

Warnings and Precautions

The adverse effects of Acthar are related primarily to its steroidogenic effects.
Acthar may increase susceptibility to new infection or reactivation of latent infections.
Suppression of the hypothalamic-pituitary-axis (HPA) may occur following prolonged therapy with the potential for adrenal insufficiency after withdrawal of the medication. Adrenal insufficiency may be minimized by tapering of the dose when discontinuing treatment. During recovery of the adrenal gland patients should be protected from the stress (e.g. trauma or surgery) by the use of corticosteroids. Monitor patients for effects of HPA suppression after stopping treatment.
Cushing's syndrome may occur during therapy but generally resolves after therapy is stopped. Monitor patients for signs and symptoms.
Acthar can cause elevation of blood pressure, salt and water retention, and hypokalemia. Blood pressure, sodium and potassium levels may need to be monitored.
Acthar often acts by masking symptoms of other diseases/disorders. Monitor patients carefully during and for a period following discontinuation of therapy.
Acthar can cause GI bleeding and gastric ulcer. There is also an increased risk for perforation in patients with certain gastrointestinal disorders. Monitor for signs of bleeding.
Acthar may be associated with central nervous system effects ranging from euphoria, insomnia, irritability, mood swings, personality changes, and severe depression, and psychosis. Existing conditions may be aggravated.
Patients with comorbid disease may have that disease worsened. Caution should be used when prescribing Acthar in patients with diabetes and myasthenia gravis.
Prolonged use of Acthar may produce cataracts, glaucoma and secondary ocular infections. Monitor for signs and symptoms.
Acthar is immunogenic and prolonged administration of Acthar may increase the risk of hypersensitivity reactions. Neutralizing antibodies with chronic administration may lead to loss of endogenous ACTH activity.
There is an enhanced effect in patients with hypothyroidism and in those with cirrhosis of the liver.
Long-term use may have negative effects on growth and physical development in children. Monitor pediatric patients.
Decrease in bone density may occur. Bone density should be monitored for patients on long-term therapy.
Pregnancy Class C: Acthar has been shown to have an embryocidal effect and should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Adverse Reactions

Common adverse reactions for Acthar are similar to those of corticosteroids and include fluid retention, alteration in glucose tolerance, elevation in blood pressure, behavioral and mood changes, increased appetite and weight gain.
Specific adverse reactions reported in IS clinical trials in infants and children under 2 years of age included: infection, hypertension, irritability, Cushingoid symptoms, constipation, diarrhea, vomiting, pyrexia, weight gain, increased appetite, decreased appetite, nasal congestion, acne, rash, and cardiac hypertrophy. Convulsions were also reported, but these may actually be occurring because some IS patients progress to other forms of seizures and IS sometimes mask other seizures, which become visible once the clinical spasms from IS resolve.

Other adverse events reported are included in the full Prescribing Information.
Please see full Prescribing Information for additional Important Safety Information.

For parents and caregivers of IS patients, please also see Medication Guide.

INDICATION AND IMPORTANT SAFETY INFORMATION

View Full

Acthar Resources

Patient education

Injection training

Related organizations

Request information

Mallinckrodt, the "M" brand mark and the Mallinckrodt Pharmaceuticals logo are trademarks of a Mallinckrodt company. Other brands are trademarks of a Mallinckrodt company or their respective owners.

US-1900451 04/19

Physician Referral/Prescription Form

INDICATION AND Important Safety Information