Triamcinolone

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

Trade Names

Kenalog
- Aerosol, spray, topical 0.2% per spray

Kenalog-10
- Injection, suspension 10 mg/mL

Kenalog-40
- Injection, suspension 40 mg/mL

Nasacort AQ
- Spray, intranasal 55 mcg/actuation

Triamcinolone
- 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%

Trianex
- Ointment 0.05%

Triderm
- Cream 0.1%

Triesence
- Injection, suspension, intravitreal 40 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 )

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.

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

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.

General Advice

  • IM
  • Injection should be made deeply into the gluteal muscle.
  • Intranasal
  • Must prime before using for the first time and if not used for more than 2 wk.
  • 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 , 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.

Drug Interactions

Aminoglutethimide

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.

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, pseudotumor cerebri, psychic disorder, quadriplegia, sensory disturbances, spinal cord infarction, 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; 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.

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, 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.

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, 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 (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).

Respiratory

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

Miscellaneous

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.

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. Carefully observe patients with frequent measurements of BP and clinical evaluation for the presence of infection, psychosocial disturbances, thromboembolism, peptic ulcers, and cataracts.


Pregnancy

Category C ; Category D ( Triesence ).

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, 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.

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 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 a 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 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.

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. Osteoporosis may develop. Acute myopathy has been reported with high-dose corticosteroids.

Ocular effects

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

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.

Thyroid

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.

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 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.
  • IM
  • 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.
  • Intranasal
  • 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.

Copyright © 2009 Wolters Kluwer Health.

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