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Case study: Madan A—International Journal of General Medicine, 2015
This case study is provided for general medical education purposes only and is not a substitute for independent clinical medical judgment. The intent of this case study is to present the experience of an individual patient, which may not represent outcomes in the overall patient population. Response to treatment may vary from patient to patient.
Woman, aged 60, referred by her primary care physician for renal dysfunction
A 60-year-old, white, obese woman was referred by her primary care physician for renal dysfunction. Patient had a renal biopsy 14 years prior that came back normal, a history of intermittent proteinuria, and a previous diagnosis of rheumatoid arthritis (RA), maintained on prednisone.
FSGS diagnosis
History of RA
Initial treatment decision1: The patient was treated with an ACE inhibitor and was maintained on 5 mg of prednisone once daily for her RA. Patient's FSGS remained stable for approximately 8 months after initiation of ACE inhibitor treatment.
FS
GS
Signs of FSGS relapse
RA
Patient also experienced painful RA "flares" during ongoing treatment with prednisone
ON
Diagnosis of optic neuritis
ACE=angiotensin-converting enzyme; UPCR=urine protein/creatinine ratio.
Patient began treatment with a 6-month regimen of Acthar Gel (40 units twice weekly) in April 2013 for FSGS.
Dosage should be individualized according to the medical condition of each patient. Frequency and dose of the drug should be determined by considering the severity of the disease and the initial response of the patient.
Sudden withdrawal of Acthar Gel after prolonged use may lead to adrenal insufficiency or recurrent symptoms. It may be necessary to taper the dose and increase the injection interval to gradually discontinue the medication.
FS
GS
At initial follow-up visit in September 2013, proteinuria and UPCR had decreased by approximately half (159 mg/dL and 4.3 g/g, respectively), and serum albumin was 3.4 g/dL.
At a follow-up visit later in September, spot urine UPCR decreased further to 1.78 g/g, and serum albumin was 3.7 g/dL. Patient also had grade 2+ bilateral pitting edema.
RA
Patient experienced fewer RA flares and her pain had decreased by about 50%.
ON
Ophthalmic follow-up showed a decrease in orbital inflammation and reduction in swelling and thickness of the optic nerve in both eyes.
Patient experienced an elevation of her blood pressure and vitreous seeding was observed.
Clinical outcomes may not be solely attributable to Acthar Gel.
Acthar Gel was primarily administered in this case to induce the remission of proteinuria in a patient with a history of intermittent proteinuria and a confirmed diagnosis of FSGS. As Dr. Madan noted in his conclusion,
"This case is interesting not only because of its effect in improving proteinuria, but also because it showed clinically beneficial ancillary effects on the patient's inflammatory disease states."
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