©2022 Stanford Medicine
A Clinical Study to Evaluate the Potential Role of ACTH Gel in Patients With Scleritis
Trial ID: NCT03465111
ATLAS study is a clinical trial to evaluate the potential role of subcutaneous adrenocorticotropic hormone (ACTH) gel in the management of non-infectious scleritis. Specifically, the ATLAS Study aims to evaluate the safety, tolerability and effect of 2 different dose regimens of ACTH gel administered by subcutaneous (SC) injection in patients with scleritis, over a period of 12 months. Scleritis is an inflammatory disease affecting the sclera (white outer coating of the eye), which causes blurring of vision, redness, tearing and painful ocular inflammatory episodes in one or both eyes. Scleritis may results in vision threatening ocular complications, if left untreated. Treatment of scleritis is usually chronic and requires systemic therapy with non-steroidal anti-inflammatory drugs, corticosteroids and immunosuppressive therapy. Due to its treatment resistance nature, scleritis remains a therapeutic challenge for many ophthalmologists. H.P. Acthar Gel (ACTH Gel) is a highly purified preparation of adrenocorticotropic hormone (ACTH) in a gel that is designed to provide extended release of the ACTH following injection. It is a FDA approved treatment for flares or on a regular basis (maintenance) in people with systemic lupus erythematosus (lupus), infantile spasms, adults with acute relapses or flares of multiple sclerosis (MS), patients with kidney diseases, among other indications. ACTH Gel is also approved for a wide range of allergic and inflammatory diseases of the eye. Given the established role of inflammation in the pathogenesis of scleritis and the anti-inflammatory effects of ACTH Gel treatment by blocking various inflammatory pathways, a beneficial outcome could be anticipated from ACTH Gel treatment in patients with scleritis.
An Open Label, Multi-centered, Randomized Phase 2 Study to Evaluate the Safety, Tolerability and Bioactivity of Subcutaneous ACTH GeL in PAtients With Scleritis: The ATLAS Study
- Adults, age ≥ 18 years;
- Able to give informed consent and attend all study visits;
- Have diagnosis of non-necrotizing scleritis determined by the Investigator to be
- Have active scleirits, defined as:
- Characteristic clinical presentation of active disease: painful inflammation, edema
and tenderness to touch radiating to the forehead, the brow, the jaw, or the sinuses.
Severity of pain associated with scleritis will be based on pain intensity, NRS scale.
- Scleral inflammation ranging from +1 to +3 as assessed by central reading center based
on standardized scleritis grading scale.
- are receiving no other treatment; or,
- are receiving prednisone (or equivalent dose of another corticosteroid) and/or at
least 1 other systemic immunosuppressant;
- Have anterior scleritis.
- Sufficient inflammation to require systemic treatment or long-term regional treatment.
- Subjects whom the investigators feel may only need short-term topical therapy should
not be enrolled.
- Best-corrected visual acuity (ETDRS method) of 20/20 to 20/400 in the study eye;
- Best- corrected visual acuity (ETDRS method) of 20/400 or better in the fellow eye
- Must have a chest radiograph within 3 months prior to enrollment with no evidence of
malignancy, infection or fibrosis.
- Females of childbearing potential must have a negative urine pregnancy test at
screening. In addition, sexually active females of childbearing potential must agree
to use TWO of the following adequate forms of contraception while on study medication:
oral, injectable, or implantable hormonal contraceptives; tubal ligation; intrauterine
device; barrier contraceptive with spermicide; or vasectomized partner.
- Males must agree to use barrier contraception (latex condoms) when engaging in sexual
activity while on study medication and for 28 days after taking the last dose of study
- Prior to study screening, potential subjects must have been evaluated and screened for
infectious etiologies by the investigators, possibly as part of standard clinical
acre; all testing to rule out infectious causes must be performed within 3 months of
screening for the ATLAS study.
- Currently active and uncontrolled scleritis, that at the determination of the
investigator, requires the initiation of corticosteroid monotherapy (or equivalent),
or prednisone therapy and immunomodulatory therapy or injections of corticosteroid
(periocular); or scleritis in subjects for whom oral corticosteroid is
contraindicated, relatively or absolutely.
- Evidence of active non-infectious scleral inflammation that at the determination of
investigator requires therapy. Such evidence can be documented by clinical
examination, photography, or ancillary testing (e.g. B-scan ultrasonography,
fluorescein angiography, optical coherence tomography). As long as the investigator
determines that the degree of inflammation can be monitored for regression or
progression, the inflammation criterion can be met.
- Not planning to undergo elective ocular surgery during the first 6 months of the
- Subjects who have developed scleritis as ocular manifestation of an underlying
systemic disease can be enrolled in the study only if the systemic therapy will not be
altered throughout the study span. If at any point during the study, the ongoing
systemic therapy needs to be altered (e.g. increase in the dose), the subject will
have to exit the study.
- If scleritis is the initial manifestation of an underlying systemic disease, and the
subjects need to be started on systemic therapy in the form of corticosteroids or
immunomodulatory therapy for the underlying disease, then the subjects will not be
eligible to participate in the study.
- Subjects with any or all of the following ocular complications associated with or
secondary to scleritis may also be eligible for enrollment:
- Evidence of active anterior uveitis (defined as +1 cells or more in the anterior
chamber or evidence of anterior vitreous inflammation on slit-lamp examination at
- Ocular hypertension, defined as intraocular pressure of ≥ 21 mmHg.
- Peripheral keratitis; defined as peripheral interstitial keratitis or thinning with
either ulcerative or non-ulcerative component.10
- Subjects who have been on immunomodulatory therapy (IMT) prior to enrollment may
participate in the study if they have been on a stable dose of IMT (at least 4 weeks
with no change in IMT dosing or addition of new IMT agents).
- Any significant ocular disease that could compromise vision in the study eye. These
include, but are not limited to:
- Diabetic retinopathy: proliferative diabetic retinopathy (PDR) or
non-proliferative diabetic retinopathy (NPDR) that compromise the vision.
- Age-related macular degeneration;
- Myopic degeneration with active subfoveal choroidal neovascularization.
- Advanced glaucoma status post trabeculectomy or tube/valve placement
- Any of the following treatments within 90 days prior to Day 0 or anticipated use of
any of the following treatments to the study eye:
- Intravitreal injections (including but not limited to steroids or anti-vascular
endothelial growth factors);
- Posterior subtenon's steroids.
- Intraocular surgery within 90 days prior to Day 0 in the study eye;
- Capsulotomy within 30 days prior to Day 0 in the study eye;
- Any known ocular surgery (including cataract extraction or capsulotomy) of the study
eye anticipated within the first 180 days following Day 0;
- Presence of posterior scleritis as the only type of scleritis (without concurrent
presence of any type of anterior scleritis;
- Intraocular pressure ≥25 mmHg in the study eye (glaucoma subjects maintained on no
more than 2 topical medications with IOP <25 mmHg are allowed to participate);
- Pupillary dilation inadequate for quality stereoscopic fundus photography in the study
- Media opacity that would limit clinical visualization;
- Presence of any form of ocular malignancy in the study eye, including choroidal
- History of herpetic infection in the study eye or adnexa;
- Presence of known active or inactive toxoplasmosis in either eye;
- Presence of ocular or periocular infection in either eye;
- Participation in other investigational drug or device clinical trials within 30 days
prior to Day 0, or planning to participate in other investigational drug or device
clinical trials within 180 days following Day 0. This includes both ocular and
non-ocular clinical trials.
- Major surgery (including joint surgery) within 8 weeks prior to screening or planned
major surgery within 6 months following randomization.
- Prior treatment with any cell-depleting therapies, including investigational agents or
approved therapies, some examples are CAMPATH, anti-CD4, anti-CD5, anti¬CD3, anti-CD19
and anti- CD20.
- Treatment with intravenous gamma globulin, plasmapheresis or Prosorba column within 6
months of baseline.
- Immunization with a live/attenuated vaccine within 4 weeks prior to baseline.
- Previous treatment with ACTH within 3 months of day 0 of study visit.
- Any previous treatment with alkylating agents such as chlorambucil, or with total
Exclusions for General Safety:
- History of severe allergic or anaphylactic reactions to proteins of porcine origin.
- Evidence of serious uncontrolled concomitant cardiovascular (including history of
congestive heart failure, uncontrolled hypertension), nervous system (include
myasthenia gravis), pulmonary (including obstructive pulmonary disease), renal,
hepatic, endocrine (includeAdrenocortical hyperfunction and primary adrenocortical
insufficiency, uncontrolled diabetes mellitus, hypothyroidism), gastrointestinal
disease (including history of or presence peptic ulcer disease, complicated
diverticulitis, ulcerative colitis, or Crohn's disease), Scleroderma or Osteoporosis.
- Current liver disease as determined by principal investigator unless related to
primary disease under investigation.
- Known active current or history of recurrent bacterial, viral, fungal, mycobacterial
or other infections (including but not limited to tuberculosis and atypical
mycobacterial disease, Hepatitis B and C, and herpes zoster, but excluding fungal
infections of nail beds).
- Any major episode of infection requiring hospitalization or treatment with IV
antibiotics within 4 weeks of screening or oral antibiotics within 2 weeks prior to
- Active TB requiring treatment within the previous 3 years. Subjects should be
evaluated for latent and/or active TB within one month of the screening as part of the
evaluation by the investigator to rule out infectious scleritis or uveitis before
referring the patient to the study. If positive, subjects should be managed following
local practice guidelines prior to initiating ACTH Gel. Subjects treated for TB with
no recurrence in 3 years are permitted.
- Primary or secondary immunodeficiency (history of or currently active)
- Evidence of active malignant disease, malignancies diagnosed within the previous 5
years (including hematological malignancies and solid tumors, except basal and
squamous cell carcinoma of the skin or carcinoma in situ of the cervix uteri that has
been excised and cured).
- Pregnant women or nursing (breast-feeding) mothers.
- Subjects with reproductive potential not willing to use an effective method of
- History of alcohol, drug or chemical abuse within 1 year prior to screening.
- Neuropathies or other conditions that might interfere with pain evaluation unless
related to primary disease under investigation.
Laboratory Exclusion Criteria (at screening):
- Alanine aminotransferase (ALT) or aspartate aminotransferase (AST) > 2 times upper
limit of normal (ULN)
- Total Bilirubin> 2 times ULN
- HbA1c > 10.0 %
- White Blood Cells < 3.0 x 109/L (3000/mm3)
- Absolute Neutrophil Count < 2.0 x 109/L (2000/mm3)
- Absolute Lymphocyte Count < 0.5 x 109/L (500/mm3)
- TSH > 4U/ml or greater than normal cut-off for the lab conducting the test
- BMD (Bone Mineral Density) < -2.5 T score
drug: ACTH (adrenocorticotropic hormone) gel
School of Medicine
300 Pasteur Drive
Stanford, CA 94305