Dose:  10 mcg/kg/dose IM or IV (see comments)

Frequency: Q Day (for treatment of infantile spasms)

Comments: Cosyntropin (Cortrosyn)is a synthetic peptide corresponding to the amino acid residues of human ACTH. It is not exactly equivalent to a biological preparation of ACTH, or corticotropin (Acthar), but cosyntropin is more potent and less allergenic than the exogenous ACTH preparations so that it is currently more commonly used for diagnostic purposes such as testing for adrenal suppression. A dose of cosyntropin 0.25 mg (250 micrograms) is equivalent to 25 units of corticotropin. An ACTH stimulation test should be performed following steroid therapy lasting more than on one week or ten to fourteen days after an abnormal test (adrenal suppression). There is some disagreement as to the dosing for an ACTH stimulation test. For neonates, cosyntropin doses of 3.5/kg micrograms and 10 micrograms/kg have been used. For infants (? > 1 month of age) a cosyntropin dose of 125 micrograms has been recommended. For children a cosyntropin dose of 250 micrograms has been recommended. During the decade of 1990 when use of dexamethasone in preterm infants was common, we used a dose of 250 micrograms given IM. Based on new information, we have decided to use 10 mcg/kg/dose as our standard dose in an ACTH stimulation test. If an endocrinologist has been consulted, ask she/he what dose she or he wished to use and the timing for the cortisol samples. In the absence of this advice, the link to ACTH stimulation test lists two protocols for performing an ACTH stimulation test.   Until a normal result has been obtained, supplemental steroids should be given in times of stress (i.e., sepsis, surgery, or illnesses with fevers) using hydrocortisone at two to four times the daily maintenance dose (50 mg/m²/day).
ACTH has been the mainstay for treating primary infantile spasms (which are rarely seen in infants less than three months of age). Doses range from 5 to 180 units daily using both the ACTH for injection and the gel formulation. Treatment duration has lasted from 2 weeks to 6 months. The only double-blind study found that ACTH and/or hydrocortisone could control symptoms following a two week course giving 20 units/day of ACTH gel (Hrachovy. J Pediatr 1983; 103:641). Baram (Pediatr 1996; 97:375) reported that ACTH 150 units/m²/day (for 2 weeks) was superior to prednisone in controlling infantile spasms.

Toxicity:  Similar to those seen with steroids . Use of ACTH can cause adrenal hyperplasia and increased secretion of endogenous steroids.

Preparations:
Cosyntropin 0.25 mg/cc (0.25 mg=25 units ACTH):

IM: Reconstitute using the 1 cc of diluent supplied to achieve a 0.25 mg/cc solutions. DO NOT REFRIGERATE the reconstituted solution.

IV: Dilute 0.25 mg in D5W or NS. The reconstituted solution should be infused at a rate of 0.04 mg/hour for 6 hours. Solutions are stable for 12 hours at room temperature.

IV: Dry ACTH is readily soluble in sterile water for injection and may be diluted with a convenient volume for administration, infused over 8 hours. Stable under refrigeration for 24 hours.

IM: Reconstitute in 1 to 2 ml of NS. Stable at room temperature up to 24 hours.

Gel may be administered as supplied. It should be stored under refrigeration.

Compatibility: Not compatible with TPN or filter.   No information available about other drugs.