Class: Corticosteroid, Glucocorticoid Triamcinolone Acetonide
- Aerosol, spray, topical 0.2% per spray
- Injection, suspension 10 mg/mL
- Injection, suspension 40 mg/mL
- Spray, intranasal 55 mcg/actuation
- Cream 0.025%
- Cream 0.1%
- Cream 0.5%
- Lotion 0.025%
- Lotion 0.1%
- Ointment 0.025%
- Ointment 0.1%
- Ointment 0.5%
- Paste, dental 0.1%
- Ointment 0.05%
- Cream 0.1%
- Injection, suspension, intravitreal 40 mg/mL
- Injection, suspension, intra-articular 20 mg/mL
- Injection, suspension, intralesional 5 mg/mL
Anti-inflammatory effect by depressing formation, release, and activity of endogenous mediators of inflammation, including prostaglandins, kinins, histamine, liposomal enzymes, and complement system. It also modifies the body's immune response.
Following single intravitreal administration, the peak aqueous humor concentrations range from 2,151 to 7,202 ng/mL. Mean C max is approximately 0.5 ng/mL and T max is 1.5 h postdose (intranasal). When injected intra-articularly, intralesionally, or sublesionally, triamcinolone can be expected to be absorbed slowly from the injection site.
Based on IV data, Vd is 99.5 to 103.4 L; binding to plasma proteins is approximately 68%.
Metabolized primarily in the liver. Metabolites are substantially less active than the parent compound.
Based on IV data, mean half-life is 88 min and Cl is 45.2 L/h. After intranasal administration, average terminal half-life is 3.1 h. Urinary and fecal excretion accounted for 40% and 60%, respectively. Some of the topical corticosteroids and their metabolites are also excreted in the bile.
Following single intravitreal administration, the mean elimination half-life is approximately 19 days in nonvitrectomized eyes and approximately 3 days in patients who have undergone vitrectomy.
Indications and UsageDental
Adjunctive treatment and for the temporary relief of symptoms associated with oral inflammatory lesions and ulcerative lesions resulting from trauma.IM ( Kenalog-40 )
Control of severe or incapacitating allergic states (eg, asthma, atopic dermatitis, contact dermatitis, drug hypersensitivity, perennial or seasonal allergic rhinitis, serum sickness, transfusion reactions); treatment of dermatologic diseases (eg, bullous dermatitis herpetiformis, exfoliative erythroderma, Stevens-Johnson syndrome, severe erythema multiforme, mycosis fungoides, pemphigus); replacement therapy for endocrine disorders (eg, primary or secondary adrenocortical insufficiency, congenital adrenal hyperplasia, hypercalcemia associated with cancer, nonsuppurative thyroiditis); control of GI diseases (eg, regional enteritis, ulcerative colitis); treatment of hematologic disorders (eg, acquired hemolytic anemia, Diamond-Blackfan anemia, selected cases of secondary thrombocytopenia, pure red cell aplasia); palliative management of neoplastic diseases (eg, leukemia, lymphoma); exacerbations of nervous system disorders (eg, multiple sclerosis, cerebral edema associated with primary or metastatic brain tumor, craniotomy, head injury); management of ophthalmic diseases (eg, sympathetic ophthalmia, temporal arteritis, uveitis, ocular inflammatory conditions unresponsive to topical corticosteroids); management of renal disease (induce diuresis or remission of proteinuria in idiopathic nephrotic syndrome or lupus erythematosus); treatment of respiratory disease (eg, berylliosis, fulminating or disseminated pulmonary tuberculosis [TB], idiopathic eosinophilic pneumonias, symptomatic sarcoidosis); adjunctive therapy in rheumatic disorders (eg, short-term administration in acute gouty arthritis, acute rheumatic carditis, ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis including juvenile rheumatoid arthritis); treatment of dermatomyositis, polymyositis, and SLE; treatment of TB meningitis; treatment of trichinosis with neurologic or myocardial involvement.Intra-articular ( Aristospan 20 mg/mL, Kenalog-10 , Kenalog-40 )
Adjunctive therapy for short-term administration in acute gouty arthritis, acute and subacute bursitis, acute nonspecific tenosynovitis, epicondylitis, rheumatoid arthritis, and synovitis or osteoarthritis.Intralesional ( Aristospan 5 mg/mL, Kenalog-10 )
Management of alopecia areata; discoid lupus erythematosus; keloids; localized hypertrophic, infiltrated, inflammatory lesions of granuloma annulare, lichen planus, lichen simplex chronicus, and psoriatic plaques; necrobiosis lipoidica diabeticorum; may be useful in cystic tumors of aponeurosis or tendon.Intranasal
Treatment of seasonal and perennial allergic rhinitis symptoms.Intravitreal ( Triesence )
Sympathetic ophthalmia, temporal arteritis, uveitis, and ocular inflammatory conditions unresponsive to topical corticosteroids; visualization during vitrectomy.Topical application
Relief of inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.
Systemic fungal infections; IM use in idiopathic thrombocytopenic purpura; administration of live or live, attenuated virus vaccines; oral inhalation as primary treatment for status asthmaticus or other acute episodes of asthma; cerebral malaria; hypersensitivity to any component of the product.
Dosage and Administration
Individualize dose based on disease being treated and response of the patient.Triamcinolone Acetonide
2.5 to 5 mg for smaller joints and 5 to 15 mg for larger joints, depending on disease being treated.Children
Initial dosage ranges from 0.11 to 1.6 mg/kg/day in 3 or 4 divided doses (3.2 to 48 mg/m 2 BSA per day).Intralesional Kenalog-10 Adults
Dose per injection varies depending on the specific disease entity and lesion being treated. Multiple sites separated by at least 1 cm may be injected, keeping in mind that the greater the total volume used, the more drug that becomes available for systemic absorption and systemic effects. Injections may be repeated weekly or at less frequent intervals if needed.Children
Initial dosage ranges from 0.11 to 1.6 mg/kg/day in 3 or 4 divided doses (3.2 to 48 mg/m 2 BSA per day)IM Kenalog-40 Adults
Usual dose is 2.5 to 100 mg/day. Recommended initial dose is 60 mg. Dose is adjusted from less than 40 to 80 mg, depending upon patient's response and duration of relief.Acute exacerbations of multiple sclerosis
160 mg daily for 1 wk followed by 64 mg every other day for 1 mo.Hay fever or pollen asthma
A single 40 to 100 mg injection may provide remission of symptoms lasting throughout the pollen season.Children
Initial dosage ranges from 0.11 to 1.6 mg/kg/day in 3 or 4 divided doses (3.2 to 48 mg/m 2 BSA per day).Intranasal Adults and children 12 y and older
Recommended starting dosage is 220 mcg/day as 2 sprays in each nostril once daily. When maximum benefit has been reached and symptoms controlled, reduce dosage to 110 mcg/day (as 1 spray in each nostril once daily).Children 6 to 12 y of age
Recommended starting dosage is 110 mcg/day as 1 spray in each nostril once daily (max, 220 mcg/day as 2 sprays in each nostril once daily).Children 2 to 5 y of age
Recommended and maximum dosage is 110 mcg/day as 1 spray in each nostril once daily.Intravitreal Adults and children Ophthalmic diseases other than visualization
Initial dose is 4 mg, with subsequent dosage as needed over the course of treatment.Visualization
Recommended dose for visualization during vitrectomy is 1 to 4 mg administered intravitreally.Topical Adults and children Cream/Ointment 0.025%
Apply thin film to affected area 2 to 4 times daily, depending on severity of the condition; rub in gently.0.1% and 0.5%
Apply thin film to affected area 2 or 3 times daily; rub in gently. Occlusive dressing may be used for management of psoriasis or recalcitrant conditions.Dental
Press a small dab (approximately ¼ inch) to the lesion until a thin film develops. May be necessary to apply 2 to 3 times a day after meals, depending on severity of symptoms.Spray
3 or 4 applications daily are generally adequate. Occlusive dressing may be used for management of psoriasis or recalcitrant conditions. Limit administration in children to the least amount compatible with an effective therapeutic regimen.Lotion
Apply thin film to affected area 2 to 4 times daily. Occlusive dressing may be used for management of psoriasis or recalcitrant conditions.Triamcinolone hexacetonide
Adults Intra-articular Aristospan 20 mg/mL
Average dose is 2 to 20 mg, depending on the size of the joint, degree of inflammation, and amount of fluid present. In general, small joints, 2 to 6 mg; large joints, 10 to 20 mg. Usual frequency of injection is every 3 to 4 wk.Intralesional or sublesional Aristospan 5 mg/mL
2 to 48 mg/day (up to 0.5 mg per square inch of skin) depending on disease entity being treated. Larger doses may be justified in certain overwhelming, acute, life-threatening conditions. Frequency determined by clinical response.Children Intra-articular Aristospan 20 mg/mL
Initial dosage is 0.11 to 1.6 mg/kg/day in 3 or 4 divided doses.Intralesional or sublesional Aristospan 5 mg/mL
Initial dosage is 0.11 to 1.6 mg/kg/day in 3 or 4 divided doses.
- Injection should be made deeply into the gluteal muscle.
- Must prime before using for the first time and if not used for more than 2 wk.
- Do not administer IV.
- Each vial and injection needle should only be used for the treatment of a single eye.
Storage/StabilityAristospan 5 and 20 mg/mL, Kenalog-10 , Kenalog-40
Store at 68° to 77°F. Protect from light; avoid freezing.Cream/Lotion/Ointment
Store at 59° to 86°F. Avoid freezing.Dental paste
Store at 68° to 77°F. Keep tightly closed.Nasacort AQ
Store at 68° to 77°F.Spray
Store at 68° to 77°F. Avoid excessive heat.Triesence
Store at 39° to 77°F. Avoid freezing. Protect from light.
May lead to loss of corticosteroid-induced adrenal suppression.Amphotericin B, diuretics
Risk of hypokalemia may be increased.Anticholinesterases
May antagonize anticholinesterase effects in myasthenia gravis. If possible, anticholinesterase agents should be withdrawn at least 24 h before starting triamcinolone.Antidiabetic agents
Because triamcinolone may increase blood glucose levels, dosage adjustments of antidiabetic agents may be needed.Cholestyramine
May increase triamcinolone Cl.Cyclosporine
Cyclosporine and triamcinolone activity may be increased. Seizures have been reported.CYP3A4 inducers (eg, barbiturates, carbamazepine, hydantoins [eg, phenytoin], rifampin)
May decrease efficacy of systemically administered triamcinolone. An increase in the triamcinolone dosage may be needed.CYP3A4 inhibitors (eg, azole antifungal agents [eg, ketoconazole], macrolide antibiotics [eg, clarithromycin])
May elevate triamcinolone plasma levels, increasing the pharmacologic effects and the risk of adverse reactions. A decrease in triamcinolone dose and/or dosing interval may be needed.Digitalis
Risk of arrhythmia due to hypokalemia may be increased.Estrogens, hormonal contraceptives
Triamcinolone plasma levels may be elevated, increasing therapeutic effects and the risk of adverse reactions. Monitor for signs of triamcinolone toxicity.Interleukin-2
The pharmacologic effects of interleukin-2 may be decreased. Avoid coadministration.Isoniazid
Serum levels may be reduced by triamcinolone, decreasing efficacy.Mifepristone
Concurrent use with triamcinolone is contraindicated during long-term corticosteroid therapy.NSAIDs, salicylates (eg, aspirin)
Risk of GI adverse reactions is increased. Serum salicylate levels may be decreased.Protease inhibitors
Triamcinolone plasma concentrations and pharmacologic effects may be increased. Hyperglycemia and adrenal suppression with iatrogenic Cushing syndrome may occur.Quinolones (eg, ciprofloxacin)
The risk of quinolone-induced tendon rupture may be increased. Patients should contact their health care provider if they develop tendon-related pain or swelling or weakness or inability to use one of their joints.Ritodrine
Maternal pulmonary edema is a possibility when coadministered with triamcinolone. If maternal pulmonary edema develops, stop ritodrine.Toxoids and live or inactivated vaccines
Because of inhibition of antibody response, patients on prolonged triamcinolone therapy may exhibit a diminished response to toxoids or live or inactivated vaccines. Replication of some organisms contained in live, attenuated vaccines may be potentiated. Administration of live or live, attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of triamcinolone.Warfarin
Variable effects on warfarin; monitor anticoagulant parameters.
Laboratory Test Interactions
Corticosteroids may suppress reactions to skin tests.
Bradycardia, cardiac arrest, cardiac arrhythmias, cardiac enlargement, circulatory collapse, CHF, fat embolism, hypertension, hypertrophic cardiomyopathy in premature infants, myocardial rupture following recent MI, pulmonary edema, syncope, tachycardia, thromboembolism, thrombophlebitis, vasculitis.
Arachnoiditis, convulsions, depression, emotional instability, euphoria, headache, increased intracranial pressure with papilledema, insomnia, malaise, meningitis, mood swings, neuritis, neuropathy, paraparesis/paraplegia, paresthesia, personality changes, pseudotumor cerebri, psychic disorder, quadriplegia, sensory disturbances, spinal cord infarction, vertigo.
DermatologicIM, intra-articular, intralesional
Acne; allergic dermatitis; cutaneous and subcutaneous atrophy; dry scalp; dry, scaly skin; edema; erythema; facial erythema; hyper- or hypopigmentation; hypertrichosis; impaired wound healing; increased sweating; lupus erythematosus–like lesions; petechiae and ecchymosis; purpura; rash; sterile abscess; striae; suppressed reactions to skin tests; thin, fragile skin; thinning scalp hair; urticaria.Topical
Allergic contact dermatitis, burning, dryness, folliculitis, hypertrichosis, hypopigmentation, irritation, itching, maceration of the skin, miliaria, perioral dermatitis, secondary infection, skin atrophy, striae.
Abnormal sensation in the eye, anterior chamber cells, anterior chamber flare, blindness associated with periocular injections, cataract, cataract cortical, cataract nuclear, cataract subcapsular, conjunctival hemorrhage, cortical blindness, dry mouth, epistaxis, exophthalmos, eye irritation, eye pain, eye pruritus, foreign body sensation in eyes, glaucoma, increased IOP, increased lacrimation, injection-site hemorrhage, nasal septal perforation, nasopharyngitis, otitis media, pharyngitis, posterior subcapsular cataracts, rhinitis, rhinorrhea, vitreous detachment, vitreous floaters.
Hypokalemic alkalosis, potassium loss, sodium retention.
Abnormal fat deposits, decreased carbohydrate tolerance, decreased glucose tolerance, development of Cushingoid state, glucosuria, hirsutism, hypertrichosis, manifestations of latent diabetes mellitus and increase in insulin and oral hypoglycemic requirements, secondary adrenocortical and pituitary unresponsiveness, suppression of growth in children.
Abdominal distention, abdominal pain, bowel dysfunction (intrathecal), diarrhea, dyspepsia, hiccups, increased appetite, nausea, oral moniliasis, pancreatitis, peptic ulcer with perforation and hemorrhage, perforation of the small and large intestine (particularly in patients with inflammatory bowel disease), tooth disorder, toothache, ulcerative esophagitis, vomiting.
Alteration in motility and number of spermatozoa, bladder dysfunction (intrathecal), cystitis, menstrual irregularities, UTI, vaginal moniliasis.
Elevated serum liver enzymes, hepatomegaly.
Negative nitrogen balance, weight gain.
Aseptic necrosis of femoral and humeral heads, back pain, bursitis, calcinosis (intra-articular or intralesionial), charcot-like arthropathy, loss of muscle mass, muscle weakness, myalgia, osteoporosis, pathologic fracture of long bones, postinjection flare (intra-articular), steroid myopathy, tendon rupture, tenosynovitis, vertebral compression fractures (intra-articular/intralesional).
Asthma, bronchitis, chest congestion, cough, pharyngolaryngeal pain, sinusitis, voice alteration.
Abnormal fat deposits, anaphylactoid reactions, anaphylaxis, anaphylactoid shock, angioedema, decreased resistance to infection, excoriation, facial edema, flu syndrome, fluid retention, immunosuppression, impaired wound healing, moon face, pain, photosensitivity.
Following intraocular injection, monitor for elevation in IOP and endophthalmitis. Monitor bone density in patients receiving long-term therapy. Routinely monitor growth of children. Monitor for IOP if steroid therapy is continued for more than 6 wk. Carefully observe patients with frequent measurements of BP and clinical evaluation for the presence of infection, psychosocial disturbances, thromboembolism, peptic ulcers, and cataracts.
Category C ; Category D ( Triesence ).
Excreted (systemically administered corticosteroids).
Children may be more susceptible to adverse reactions from topical use. Data for safety and efficacy are available for treatment of nephrotic syndrome in children older than 2 y, and for aggressive lymphomas and leukemia for children older than 1 mo.Intralesional/Intra-articular
Not for use in newborns. These products contain benzyl alcohol, which has been associated with fatal gasping syndrome in premature infants.Intranasal
Safety and efficacy not established in children younger than 2 y.
May require lower doses. Use with caution, usually starting at the low end of the dosage range, because of the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant diseases or other drug therapy.
Reactions, including anaphylaxis, may occur.
Use drug with caution.
There is an enhanced effect of corticosteroids in patients with cirrhosis.
Special Risk Patients
Use corticosteroids with caution in patients with active or quiescent TB infection; untreated systemic fungal, bacterial, parasitic, or viral infections; or ocular herpes simplex.
Oral inhalation is not indicated for rapid relief of bronchospasm.
Prolonged therapy may lead to hypothalamic-pituitary-adrenal axis suppression.
Transfer of patients from systemic steroid therapy to inhalation therapy may unmask allergic conditions previously suppressed by systemic steroid therapy (eg, rhinitis).
Present in the parenteral products and has been associated with fatal gasping syndrome in premature infants.
Bronchospasm may occur with an immediate increase in wheezing following dosing. Requires immediate treatment with a fast-acting inhaled bronchodilator.
Existing emotional instability or psychotic tendencies may be aggravated. CNS effects ranging from euphoria, insomnia, mood swings, personality changes, and severe depression may occur.
May cause BP elevation, salt and water retention, and increased potassium and calcium excretion. Use with caution in patients with hypertension, CHF, left ventricular free wall rupture, or recent MI.
Use with caution in patients with active or latent peptic ulcer, diverticulitis, fresh intestinal anastomosis, and nonspecific ulcerative colitis.
Drug may be harmful in patients with chronic active hepatitis positive for hepatitis B surface antigen.
Elevated IOP may occur in 20% to 60% of patients receiving triamcinolone and may persist for up to 6 mo following injection.
Risks related to infections with any pathogen, including viral, bacterial, fungal, protozoan, or helminthic infections, may be increased. Signs of infection may be masked, resistance to new infections may be reduced, and host-defense mechanisms to prevent dissemination of infection may be decreased.
Intra-articular and soft tissue injection
Intra-articularly injected drug may be systemically absorbed. Avoid injection into an infected or previously infected site. Injection into unstable joints is not recommended. Intra-articular injection may result in damage to joint tissue.
Has been reported in patients receiving corticosteroids for chronic conditions.
May be activated or exacerbated, including intercurrent infections (eg, TB).
Local nasal effects
Candida infection, epistaxis, nasal septal perforation, and impaired wound healing may occur.
Bone formation may be decreased, while bone resorption may be increased. Osteoporosis may develop. Acute myopathy has been reported with high-dose corticosteroids.
Do not use in ocular herpes simplex. Glaucoma and/or cataracts may occur.
Do not inject subcutaneously. Avoid injection into deltoid muscle and repeated IM injection into same site.
Increased dosage of rapidly acting corticosteroid may be needed before, during, and after stressful situations.
Metabolic Cl of corticosteroids is decreased in hypothyroid patients and increased in hyperthyroid patients. Changes in thyroid status may necessitate adjustment in dose.
Traumatic brain injury
Mortality may be increased; avoid use of high doses of corticosteroids.
Chickenpox and measles may be more serious and sometimes fatal in patients receiving corticosteroids.
Abrupt discontinuation may result in adrenal insufficiency.
Acne, central obesity, ecchymoses, electrolyte and fluid imbalance (excessive or long-term use), hirsutism, hyperglycemia, hyperlipidemia, hypertension, moon face, myopathy, osteoporosis, peptic ulcer, sexual dysfunction, striae.
- Advise patients to read the patient information leaflet before starting therapy and again with each refill.
- Advise patients to continue taking other medications for same condition as prescribed by health care provider.
- Advise patients that dose may be changed periodically, depending on how well symptoms are controlled.
- Explain that effects of drug are not immediate. Benefit requires daily use as instructed and usually begins to occur within 1 or 2 days, but full benefit may take 1 to 2 wk, depending on the condition being treated and the dose and route of administration of medication being used.
- Caution patient not to increase dose, but to inform health care provider if symptoms do not seem to be improving or are worsening.
- Instruct diabetic patients to monitor blood glucose more frequently when drug is started or dose is changed, and to inform health care provider of significant changes in readings.
- Advise patient to immediately notify health care provider if any of the following occurs: black, tarry stools; fever; muscle weakness; sore throat; swelling of feet or ankles; vomiting of blood; or other signs of infection.
- Advise patients to avoid exposure to chickenpox and measles and to seek medical advice immediately if exposed.
- If patient is being converted from oral to inhaled or intranasal corticosteroids, review signs and symptoms of adrenal insufficiency, which may occur days or weeks after conversion is complete.
- Advise patients that dietary salt restriction and potassium supplementation may be necessary.
- Dental paste
- Teach patients proper technique for applying the paste: press small dab (about ¼ inch) on the lesion until thin film develops. Caution patient not to rub the paste into the lesion.
- Advise patients to apply at bedtime if being used once daily and after meals if being used more than once daily.
- Advise patients to stop using and inform health care provider if any of the following local reactions occur: burning, irritation, itching, new blistering or peeling, new sores.
- Advise patients to carry medical identification (eg, card, bracelet) indicating use of corticosteroids, the condition(s) being treated, and possible need for supplemental systemic corticosteroids during periods of stress or severe asthma attack.
- Caution patients not to suddenly stop taking this medication after more than 1 mo of use. Advise patient that if medication needs to be discontinued after prolonged therapy (eg, more than 1 mo), it will be slowly withdrawn to prevent adrenal insufficiency.
- Review signs and symptoms of adrenal insufficiency (eg, abdominal, joint, or muscle pain; depression; dizziness; fatigue; hypotension; nausea). Instruct patients to immediately seek medical care if symptoms suggestive of adrenal insufficiency develop.
- Review proper administration technique. Have patient demonstrate technique to ensure effective use of the nasal spray.
- Instruct patients not to stop the medication once symptoms have been controlled. Continued daily use is necessary to control symptoms.
- Instruct patients to use with caution if sores develop or injuries occur in nasal passages. Drug may prevent or slow proper healing.
- Advise patients to report the following symptoms to health care provider: nasal irritation, nosebleed, sneezing.
- Advise patients using pump spray to discard bottle when labeled number of sprays have been used even if bottle is not completely empty.
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