Cosyntropin

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# Overview
Cosyntropin is an endocrine metabolic agent that is FDA approved for the diagnosis of adrenocortical insufficiency.   Common adverse reactions include bradyarrhythmia, hypertension, tachycardia, anaphylaxis, and hypersensitivity reaction.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)

# Indications
- CORTROSYN (cosyntropin) for Injection is intended for use as a diagnostic agent in the screening of patients presumed to have adrenocortical insufficiency. Because of its rapid effect on the adrenal cortex it may be utilized to perform a 30-minute test of adrenal function (plasma cortisol response) as an office or outpatient procedure, using only 2 venipunctures.
- Severe hypofunction of the pituitary - adrenal axis is usually associated with subnormal plasma cortisol values but a low basal level is not per se evidence of adrenal insufficiency and does not suffice to make the diagnosis. Many patients with proven insufficiency will have normal basal levels and will develop signs of insufficiency only when stressed. For this reason a criterion which should be used in establishing the diagnosis is the failure to respond to adequate corticotropin stimulation. When presumptive adrenal insufficiency is diagnosed by a subnormal CORTROSYN test, further studies are indicated to determine if it is primary or secondary.
- Primary adrenal insufficiency (Addisons disease) is the result of an intrinsic disease process, such as tuberculosis within the gland. The production of adrenocortical hormones is deficient despite high ACTH levels (feedback mechanism). Secondary or relative insufficiency arises as the result of defective production of ACTH leading in turn to disuse atrophy of the adrenal cortex. It is commonly seen, for example, as result of corticosteroid therapy, Sheehans syndrome and pituitary tumors or ablation.
- The differentiation of both types is based on the premise that a primarily defective gland cannot be stimulated by ACTH whereas a secondarily defective gland is potentially functional and will respond to adequate stimulation with ACTH. Patients selected for further study as the result of a subnormal CORTROSYN test should be given a 3 or 4 day course of treatment with Repository Corticotropin Injection USP and then retested. Suggested doses are 40 USP units twice daily for 4 days or 60 USP units twice daily for 3 days. Under these conditions little or no increase in plasma cortisol levels will be seen in Addisons disease whereas higher or even normal levels will be seen in cases with secondary adrenal insufficiency.

# Dosage
- CORTROSYN (cosyntropin) for Injection may be administered intramuscularly or as a direct intravenous injection when used as a rapid screening test of adrenal function. It may also be given as an intravenous infusion over a 4 to 8 hour period to provide a greater stimulus to the adrenal glands. Doses of CORTROSYN 0.25 to 0.75 mg have been used in clinical studies and a maximal response noted with the smallest dose.
- A suggested method for a rapid screening test of adrenal function has been described by Wood and Associates (1). A control blood sample of 6 to 7 mL is collected in a heparinized tube. Reconstitute 0.25 mg of CORTROSYN with 1mL of 0.9% Sodium Chloride Injection, USP and inject intramuscularly. The reconstituted drug product should be inspected visually for particulate matter and discoloration prior to injection. Reconstituted CORTROSYN should not be retained. In the pediatric population, aged 2 years or less, a dose of 0.125 mg will often suffice. A second blood sample is collected exactly 30 minutes later. Both blood samples should be refrigerated until sent to the laboratory for determination of the plasma cortisol response by some appropriate method. If it is not possible to send them to the laboratory or perform the fluorimetric procedure within 12 hours, then the plasma should be separated and refrigerated or frozen according to need.
- Two alternative methods of administration are intravenous injection and infusion. CORTROSYN can be injected intravenously in 2 to 5 mL of saline over a 2-minute period. When given as an intravenous infusion: CORTROSYN, 0.25 mg may be added to glucose or saline solutions and given at the rate of approximately 40 micrograms per hour over a 6-hour period. It should not be added to blood or plasma as it is apt to be inactivated by enzymes. Adrenal response may be measured in the usual manner by determining urinary steroid excretion before and after treatment or by measuring plasma cortisol levels before and at the end of the infusion. The latter is preferable because the urinary steroid excretion does not always accurately reflect the adrenal or plasma cortisol response to ACTH.
- The usual normal response in most cases is an approximate doubling of the basal level, provided that the basal level does not exceed the normal range. Patients receiving cortisone, hydrocortisone or spironolactone should omit their pre-test doses on the day selected for testing. Patients taking inadvertent doses of cortisone or hydrocortisone on the test day and patients taking spironolactone or women taking drugs which contain estrogen may exhibit abnormally high basal plasma cortisol levels.
- A paradoxical response may be noted in the cortisone or hydrocortisone group as seen in a decrease in plasma cortisol values following a stimulating dose of CORTROSYN.
- In the spironolactone or estrogen group only a normal incremental response is to be expected. Many patients with normal adrenal function, however, do not respond to the expected degree so that the following criteria have been established to denote a normal response:
- 1. The control plasma cortisol level should exceed 5 micrograms/100 mL.
- 2. The 30-minute level should show an increment of at least 7 micrograms/100 mL above the basal level.
- 3. The 30-minute level should exceed 18 micrograms/100 mL. Comparable figures have been reported by Greig and co-workers.
- Plasma cortisol levels usually peak about 45 to 60 minutes after an injection of CORTROSYN and some prefer the 60-minute interval for testing for this reason. While it is true that the 60-minute values are usually higher than the 30-minute values, the difference may not be significant enough in most cases to outweigh the disadvantage of a longer testing period. If the 60-minute test period is used, the criterion for a normal response is an approximate doubling of the basal plasma cortisol value (2).
- In patients with a raised plasma bilirubin or in patients where the plasma contains free hemoglobin, falsely high fluorescence measurements will result. The test may be performed at any time during the day but because of the physiological diurnal variation of plasma cortisol the criteria listed by Wood cannot apply. It has been shown that basal plasma cortisol levels and the post CORTROSYN increment exhibit diurnal changes. However, the 30-minute plasma cortisol level remains unchanged throughout the day so that only this single criterion should be used (3).
- Parenteral drug products should be inspected visually for particulate matter and discoloration whenever solution and container permit. Reconstituted CORTROSYN should not be retained.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
- There is limited information regarding Off-Label Guideline-Supported Use of Cosyntropin in adult patients.

### NonGuideline-Supported Use
- There is limited information regarding Off-Label NonGuideline-Supported Use of Cosyntropin in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
- There is limited information regarding FDA-Labeled Use of Cosyntropin in pediatric patients.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
- There is limited information regarding Off-Label Guideline-Supported Use of Cosyntropin in pediatric patients.

### NonGuideline-Supported Use
- There is limited information regarding Off-Label NonGuideline-Supported Use of Cosyntropin in pediatric patients.

# Contraindications
- The only contraindication to CORTROSYN (cosyntropin) for Injection is a history of a previous adverse reaction to it.

# Warnings
- There is limited information regarding Warning of Cosyntropin in the drug label.

# Adverse Reactions

## Clinical Trials Experience
- Since CORTROSYN (cosyntropin) for Injection is intended for diagnostic and not therapeutic use, adverse reactions other than a rare hypersensitivity reaction are not anticipated. A rare hypersensitivity reaction usually associated with a pre-existing allergic disease and/or a previous reaction to natural ACTH is possible. Symptoms may include slight whealing with splotchy erythema at the injection site. There have been rare reports of anaphylactic reaction. The following adverse reactions have been reported in patients after the administration of CORTROSYN and the association has been neither confirmed nor refuted:

## Postmarketing Experience
- There is limited information regarding Postmarketing Experience of Cosyntropin in the drug label.

# Drug Interactions
- Corticotropin may accentuate the electrolyte loss associated with diuretic therapy.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): 
Pregnancy Category C. Animal reproduction studies have not been conducted with CORTROSYN (cosyntropin) for Injection. It is also not known whether CORTROSYN can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. CORTROSYN should be given to a pregnant woman only if clearly needed.
Pregnancy Category (AUS):
- There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Cosyntropin in women who are pregnant.

### Labor and Delivery
- There is no FDA guidance on use of Cosyntropin during labor and delivery.

### Nursing Mothers
- It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when CORTROSYN (cosyntropin) for Injection is administered to a nursing woman.

### Pediatric Use
- There is no FDA guidance on the use of Cosyntropin with respect to pediatric patients.

### Geriatic Use
- There is no FDA guidance on the use of Cosyntropin with respect to geriatric patients.

### Gender
- There is no FDA guidance on the use of Cosyntropin with respect to specific gender populations.

### Race
- There is no FDA guidance on the use of Cosyntropin with respect to specific racial populations.

### Renal Impairment
- There is no FDA guidance on the use of Cosyntropin in patients with renal impairment.

### Hepatic Impairment
- There is no FDA guidance on the use of Cosyntropin in patients with hepatic impairment.

### Females of Reproductive Potential and Males
- There is no FDA guidance on the use of Cosyntropin in women of reproductive potentials and males.

### Immunocompromised Patients
- There is no FDA guidance one the use of Cosyntropin in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Intravenous
- Intramuscularly

### Monitoring
- There is limited information regarding Monitoring of Cosyntropin in the drug label.

# IV Compatibility
- There is limited information regarding IV Compatibility of Cosyntropin in the drug label.

# Overdosage
- There is limited information regarding Chronic Overdose of Cosyntropin in the drug label.

# Pharmacology

## Mechanism of Action
- The pharmacologic profile of CORTROSYN is similar to that of purified natural ACTH. It has been established that 0.25 mg of CORTROSYN will stimulate the adrenal cortex maximally and to the same extent as 25 units of natural ACTH. This dose of CORTROSYN will produce maximal secretion of 17-OH corticosteroids, 17- ketosteroids and / or 17 - ketogenic steroids.

## Structure
- CORTROSYN (cosyntropin) for Injection is a sterile lyophilized powder in vials containing 0.25 mg of CORTROSYN and 10 mg of mannitol to be reconstituted with 1 mL of 0.9% Sodium Chloride Injection, USP. Administration is by intravenous or intramuscular injection. Cosyntropin is  1 - 24 corticotropin, a synthetic subunit of ACTH. It is an open chain polypeptide containing, from the N terminus, the first 24 of the 39 amino acids of natural ACTH. The sequence of amino acids in the 1 - 24 compound is as follows:

## Pharmacodynamics
- There is limited information regarding Pharmacodynamics of Cosyntropin in the drug label.

## Pharmacokinetics
- There is limited information regarding Pharmacokinetics of Cosyntropin in the drug label.

## Nonclinical Toxicology
Carcinogenesis, Mutagenesis, Impairment of Fertility
- Long term studies in animals have not been performed to evaluate carcinogenic or mutagenic potential or impairment of fertility. A study in rats noted inhibition of reproductive function like natural ACTH.

# Clinical Studies
- There is limited information regarding Clinical Studies of Cosyntropin in the drug label.

# How Supplied
- Box of 10 vials of CORTROSYN (cosyntropin) for Injection 0.25 mg
NDC # 0548-5900-00

## Storage
- Store at 15-30C (59-86F).
- CORTROSYN is intended as a single dose injection and contains no antimicrobial preservative. Any unused portion should be discarded.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
There is limited information regarding Patient Counseling Information of Cosyntropin in the drug label.

# Precautions with Alcohol
- Alcohol-Cosyntropin interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- CORTROSYN  

# Look-Alike Drug Names
There is limited information regarding Cosyntropin Look-Alike Drug Names in the drug label.

# Drug Shortage Status

# Price