The rationale, dosage, and side effects of ACTH treatment of infantile spasms are reviewed from the Department of Neurology, University of Southern California School of Medicine, and Children’s Hospital of Los Angeles, CA. Admission to hospital is recommended for the initiation of ACTH therapy so that baseline laboratory tests can be obtained and response to treatment can be supervised for the first three days. The author recommends an initial dose of ACTH 150 units/m2/day (Acthar gel), 80 units/ml intramuscularly in two divided doses for one week. In the second week the dose recommended is 75 units/m2/day in one; daily dose for one week. In the third week the dose is 75 units/m2 every other day for one week. ACTH is gradually withdrawn over the next nine weeks. A change in the lot number of ACTH gel is indicated when no response occurs in two weeks. The author admits controversy concerning the dose, duration of therapy, and effectiveness of ACTH relative to oral steroids as well as the long-term benefit of either of these therapies. 
COMMENT. Exceptionally large doses of ACTH recommended in this report were also used by Riikonen R and Simell O in the treatment of infantile spasms associated with tuberous sclerosis. (See Ped Neur Briefs April 1990; 4:30-31). There was an unusually high incidence of side effects, including arterial hypertension, with two patients developing cardiac failure and three with fluid retention in polycystic kidneys. My own preference is for smaller doses (10-20 units of Acthar gel daily by intramuscular injection for three weeks) with the avoidance of cushingoid complications and a lesser incidence of other side effects. Early treatment is important in terms of the response to therapy and possibly in relation to subsequent development.