Triamcinolone

Pronunciation: (TRYE-am-SIN-oh-lone)
Class: Corticosteroid, Glucocorticoid Triamcinolone Acetonide

Trade Names

Azmacort
- Aerosol, inhalation 75 mcg/actuation

Kenalog
- Aerosol, spray, topical 0.2% per spray
- Cream 0.025%
- Cream 0.1%
- Ointment 0.025%
- Ointment 0.1%

Kenalog-10
- Injection, suspension 10 mg/mL

Kenalog-40
- Injection, suspension 40 mg/mL

Nasacort AQ
- Spray, intranasal 55 mcg/actuation

Oracort
- Paste, dental 0.1%

Triamcinolone
- Cream 0.5%
- Lotion 0.025%
- Lotion 0.1%
- Ointment 0.5%

Triderm
- Cream 0.1%

Triesence
- Injection, suspension, intravitreal 40 mg/mL

Trivaris
- Injection, suspension gel, intra-articular, intramuscular, or intravitreal 80 mg/mL

Aristospan (Canada)
Triamcinolone Hexacetonide

Aristospan
- Injection, suspension, intra-articular 20 mg/mL
- Injection, suspension, intralesional 5 mg/mL

Pharmacology

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.

Pharmacokinetics

Absorption

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.

Distribution

Based on IV data, Vd is 99.5 to 103.4 L; binding to plasma proteins is approximately 68%.

Metabolism

Metabolized primarily in the liver. Metabolites are substantially less active than the parent compound.

Elimination

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 Usage

Dental

Adjunctive treatment and for the temporary relief of symptoms associated with oral inflammatory lesions and ulcerative lesions resulting from trauma.

IM ( Kenalog-40 , Trivaris )

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 disease (eg, bullous dermatitis herpetiformis, exfoliative dermatitis, Stevens-Johnson syndrome, 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); 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); 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 , Trivaris )

Adjunctive therapy for short-term administration in acute gouty arthritis, acute and subacute bursitis, acute nonspecific tenosynovitis, epicondylitis, rheumatoid arthritis, and synovitis of 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 , Trivaris )

Sympathetic ophthalmia, temporal arteritis, uveitis, and ocular inflammatory conditions unresponsive to topical corticosteroids; visualization during vitrectomy ( Triesence only).

Oral inhalation

Maintenance treatment of asthma as prophylactic therapy; use in asthma patients requiring systemic corticosteroid administration.

Topical application

Relief of inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.

Contraindications

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
Intra-articular Adults and Children

2.5 to 5 mg for smaller joints and 5 to 15 mg for larger joints, depending on disease being treated.

Intralesional Adults and Children

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.

IM Adults and Children 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.

Adults

Recommended initial dose is 60 mg, injected deeply into gluteal muscle. Dose is adjusted from less than 40 to 80 mg, depending upon patient's response and duration of relief.

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).

Intranasal Adults and Children 12 y of age and older Nasacort AQ

Recommended starting dosage is 220 mcg/day as 2 sprays in each nostril once daily. When max 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 Nasacort AQ

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 Nasacort AQ

Recommended and max 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 ( Triesence ) or a 4 mg single dose ( Trivaris ) administered intravitreally.

Oral inhalation Adults

Titrate to the lowest effective dose once asthma stability has been achieved.

Azmacort

2 inhalations (150 mcg) 3 to 4 times daily or 4 inhalations (300 mcg) twice daily (max, 16 inhalations [1,200 mcg] daily). Higher initial doses (12 to 16 inhalations [900 to 1,200 mcg] daily) may be considered for more severe asthma.

Children 6 to 12 y of age Azmacort

Recommended dosage is 1 to 2 inhalations (75 to 150 mcg) 3 to 4 times a day or 2 to 4 inhalations (150 to 300 mcg) twice daily (max, 12 inhalations [900 mcg] daily).

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.

Kenalog spray

3 or 4 applications daily are generally adequate. Occlusive dressing may be used for management of psoriasis or recalcitrant conditions. Limit administration to 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 of 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.

General Advice

• Intranasal
• Must prime before using for the first time and if not used for more than 2 wk.

• Inhalation
• Shake well before use. Rinse mouth after inhalation.

• Triesence
• Do not administer IV.
• Each vial and injection needle should only be used for the treatment of a single eye.

Storage/Stability

Aristospan 5 and 20 mg/mL, Kenalog-10 injection, Kenalog-40 injection

Store at 68° to 77°F. Protect from light; avoid freezing.

Azmacort

Store at 68° to 77°F. Shake well before using.

Kenalog spray

Store at 68° to 77°F. Avoid excessive heat.

Nasacort AQ

Store at 68° to 77°F.

Oracort dental paste

Store at 68° to 77°F. Keep tightly closed.

Triamcinolone cream/lotion/ointment, Triderm cream

Store at 59° to 86°F. Avoid freezing.

Triesence

Store at 39° to 77°F. Avoid freezing. Protect from light.

Trivaris

Store at 36° to 46°F. Avoid freezing. Protect from light.

Drug Interactions

Aminoglutethimide

May lead to loss of corticosteroid-induced adrenal suppression.

Amphotericin B, potassium-sparing diuretics

Risk of hypokalemia may be increased.

Anticholinesterases

May antagonize anticholinesterase effects in myasthenia gravis.

Antidiabetic agents

Because triamcinolone may increase blood sugar 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.

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.

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.

Interleukin-2

The pharmacologic effects of interleukin-2 may be decreased.

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.

Protease inhibitors

Triamcinolone plasma concentrations and pharmacologic effects may be increased.

Quinolones (eg, ciprofloxacin)

The risk of quinolone-induced tendon rupture may be increased.

Ritodrine

Maternal pulmonary edema is a possibility when coadministered with triamcinolone.

Salicylates

Systemic administration may reduce serum levels and efficacy of salicylates.

Toxoids and live or inactivated vaccines

Because of inhibition of antibody response, patients on prolonged triamcinolone therapy may exhibit a diminished response to toxoids, live or inactivated vaccines, or skin tests. 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.

Adverse Reactions

Cardiovascular

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.

CNS

Arachnoiditis, convulsions, depression, emotional instability, euphoria, headache, increased intracranial pressure with papilledema, insomnia, malaise, meningitis, mood swings, neuritis, neuropathy, paraparesis/paraplegia, paresthesia, personality changes, psychic disorder, sensory disturbances, vertigo.

Dermatologic

IM, 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; 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.

EENT

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, 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.

Electrolytes

Hypokalemic alkalosis, potassium loss, sodium retention.

Endocrine

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, moon face, secondary adrenocortical and pituitary unresponsiveness, suppression of growth in children.

GI

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.

Genitourinary

Alteration in motility and number of spermatozoa, bladder dysfunction (intrathecal), cystitis, menstrual irregularities, UTI, vaginal moniliasis.

Hepatic

Elevated serum liver enzymes, hepatomegaly.

Metabolic-Nutritional

Negative nitrogen balance, weight gain.

Musculoskeletal

Aseptic necrosis of femoral and humeral heads, back pain, bursitis, calcinosis, 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).

Respiratory

Asthma, bronchitis, chest congestion, cough, pharyngolaryngeal pain, sinusitis, voice alteration.

Miscellaneous

Abnormal fat deposits, anaphylactoid reactions, anaphylaxis, angioedema, decreased resistance to infection, excoriation, facial edema, flu syndrome, fluid retention, immunosuppression, impaired wound healing, moon face, pain, photosensitivity.

Precautions

Monitor 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.

Pregnancy

Category C ; Category D ( Triesence , Trivaris ).

Lactation

Excreted (systemically administered corticosteroids).

Children

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 of age, and for aggressive lymphomas and leukemia for children older than 1 mo of age.

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 of age.

Oral inhalational

Safety and efficacy not established in children younger than 6 y of age.

Elderly

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.

Hypersensitivity

Reactions, including anaphylaxis, may occur.

Renal Function

Use drug with caution.

Hepatic Function

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.

Acute asthma

Oral inhalation is not indicated for rapid relief of bronchospasm.

Adrenal suppression

Prolonged therapy may lead to hypothalamic-pituitary-adrenal (HPA) axis suppression.

Allergy

Transfer of patients from systemic steroid therapy to inhalation therapy may unmask allergic conditions previously suppressed by systemic steroid therapy (eg, rhinitis).

Benzyl alcohol

Present in the parenteral products and has been associated with fatal gasping syndrome in premature infants.

Bronchospasm

Bronchospasm may occur with an immediate increase in wheezing following dosing. Requires immediate treatment with fast-acting inhaled bronchodilator.

CNS effects

Existing emotional instability or psychotic tendencies may be aggravated. CNS effects ranging from euphoria, insomnia, mood swings, personality changes, and severe depression may occur.

CV effects

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.

GI

Use with caution in patients with active or latent peptic ulcer, diverticulitis, fresh intestinal anastomosis, and nonspecific ulcerative colitis.

Hepatitis

Drug may be harmful in patients with chronic active hepatitis positive for hepatitis B surface antigen.

Increased IOP

Elevated IOP may occur in 20% to 60% of patients receiving triamcinolone injection and may persist for up to 6 mo following injection.

Infections

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.

Inhalant only

Transfer from oral corticosteroids to inhaled corticosteroids has resulted in death due to adrenal insufficiency related to lower systemic availability. A number of months are required for recovery of HPA axis suppression. Patients maintained on prednisone 20 mg/day or more may be at higher risk. During periods of stress or severe asthma attack, instruct patients who have been withdrawn from systemic corticosteroids to resume oral steroids immediately.

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.

Kaposi sarcoma

Has been reported in patients receiving corticosteroids for chronic conditions.

Latent disease

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.

Musculoskeletal

Bone formation may be decreased, while bone resorption may be increased. Acute myopathy has been reported with high-dose corticosteroids.

Ocular effects

Do not use in ocular herpes simplex. Glaucoma and/or cataracts may occur.

Peptic ulcer

Drug may contribute to peptic ulceration, especially in large doses.

Repository injections

Do not inject subcutaneously. Avoid injection into deltoid muscle and repeated IM injection into same site.

Stress

Increased dosage of rapidly acting corticosteroid may be needed before, during, and after stressful situations.

Traumatic brain injury

Mortality may be increased; avoid use of high doses of corticosteroids.

Thyroid

Metabolic Cl of corticosteroids is decreased in hypothyroid patients and increased in hyperthyroid patients. Changes in thyroid status may necessitate adjustment in dose.

Viral infections

Chickenpox and measles may be more serious and sometimes fatal in patients receiving corticosteroids.

Withdrawal

Abrupt discontinuation may result in adrenal insufficiency.

Overdosage

Symptoms

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.

Patient Information

• Advise patient to read the patient information leaflet before starting therapy and again with each refill.
• Advise patient to continue taking other medications for same condition as prescribed by health care provider.
• Advise patient 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 patient 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 patient 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 and potassium supplementation may be necessary.

• Oral Inhalation
• Review proper administration technique. Have patient demonstrate technique to ensure effective use of the metered-dose inhaler and attached spacer.
• Warn patient that drug is an asthma controller and is not to be used to treat an acute asthma attack. Rescue medication (bronchodilator) must be used to obtain rapid relief of asthma symptoms.
• Instruct patient not to stop using the medication once symptoms have been controlled. Continued daily use is necessary to control symptoms.
• Advise patient to discard the aerosol canister when the labeled number of doses has been used.
• Instruct patient to carry medical identification (eg, card, bracelet) if experiencing acute severe asthma attacks requiring rapid systemic treatment.
• Advise patient to report the following symptoms to health care provider: cough, dry mouth, facial swelling, rash, sore throat or mouth, worsening asthma symptoms (increasing need for bronchodilator).

• Intranasal
• Review proper administration technique. Have patient demonstrate technique to ensure effective use of the nasal spray.
• Instruct patient not to stop the medication once symptoms have been controlled. Continued daily use is necessary to control symptoms.
• Instruct patient to use with caution if sores develop or injuries occur in nasal passages. Drug may prevent or slow proper healing.
• Advise patient to report the following symptoms to health care provider: nasal irritation, nosebleed, sneezing.
• Advise patient using pump spray to discard bottle when labeled number of sprays have been used even if bottle is not completely empty.

• IM
• Advise patient 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 patient 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 patient to immediately seek medical care if symptoms suggestive of adrenal insufficiency develop.

• Dental Paste
• Teach patient 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 patient to apply at bedtime if being used once daily and after meals if being used more than once daily.
• Advise patient 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.

Copyright © 2009 Wolters Kluwer Health.