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- Triamcinolone Acetonide
- Triamcinolone Acetonide, Parenteral
- Triamcinolone Hexacetonide
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Kit, Injection, as acetonide:
Arze-Ject-A: 40 mg/mL (3 x 1 mL) [DSC] [contains benzyl alcohol, polysorbate 80]
P-Care K40: 40 mg/mL (1 x 1 mL) [contains benzyl alcohol, polysorbate 80]
P-Care K80: 40 mg/mL (2 x 1 mL) [contains benzyl alcohol, polysorbate 80]
Pod-Care 100K: 40 mg/mL (1 x 1 mL) [contains benzyl alcohol, polysorbate 80]
Pro-C-Dure 5: 40 mg/mL (2 x 1 mL) [contains benzyl alcohol, polysorbate 80]
Pro-C-Dure 6: 40 mg/mL (3 x 1 mL) [contains benzyl alcohol, polysorbate 80]
ReadySharp Triamcinolone: 40 mg/mL (1 x 1 mL) [contains benzyl alcohol, polysorbate 80]
Suspension, Injection, as acetonide:
Kenalog: 10 mg/mL (5 mL); 40 mg/mL (1 mL, 5 mL, 10 mL) [contains benzyl alcohol, polysorbate 80]
Generic: 40 mg/mL (1 mL, 5 mL, 10 mL)
Suspension, Injection, as hexacetonide:
Aristospan Intra-Articular: 20 mg/mL (1 mL [DSC], 5 mL [DSC]) [contains benzyl alcohol]
Aristospan Intralesional: 5 mg/mL (5 mL [DSC]) [contains benzyl alcohol]
Suspension Reconstituted ER, Intra-articular, as acetonide:
Zilretta: 32 mg (1 ea) [contains polysorbate 80]
Brand Names: U.S.
- Aristospan Intra-Articular [DSC]
- Aristospan Intralesional [DSC]
- Arze-Ject-A [DSC]
- P-Care K40
- P-Care K80
- Pod-Care 100K
- Pro-C-Dure 5
- Pro-C-Dure 6
- ReadySharp Triamcinolone
- Corticosteroid, Systemic
A long acting corticosteroid with minimal sodium-retaining potential. Decreases inflammation by suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability; suppresses the immune system by reducing activity and volume of the lymphatic system; suppresses adrenal function at high doses
Vd: IV (acetonide): 99.5 L
Hepatic (Asare 2007)
Urine (75% primarily); bile and feces (25%) (Asare 2007)
Onset of Action
Adrenal suppression: IM (acetonide): 24 to 48 hours; Intra-articular: 12 to 24 hours
Duration of Action
Adrenal suppression: IM (acetonide): 30 to 40 days; Intra-articular: 30 to 42 days
Plasma: 300 minutes (Asare 2007)
Use: Labeled Indications
Intra-articular or soft tissue administration: As adjunctive therapy for short-term administration in acute gouty arthritis, acute and subacute bursitis, acute nonspecific tenosynovitis, epicondylitis, rheumatoid arthritis (RA), or synovitis of osteoarthritis; management of osteoarthritis (OA) knee pain.
Intralesional administration (triamcinolone hexacetonide and triamcinolone acetonide [Kenalog-10 only]): Alopecia areata; discoid lupus erythematosus; keloids; localized hypertrophic, infiltrated, inflammatory lesions of granuloma annulare, lichen planus, lichen simplex chronicus (neurodermatitis), and psoriatic plaques; necrobiosis lipoidica diabeticorum; cystic tumors of an aponeurosis or tendon (ganglia).
Intramuscular administration (triamcinolone acetonide [Kenalog-40] only):
Allergic states: Control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment in asthma, drug hypersensitivity reactions, perennial or seasonal allergic rhinitis, serum sickness, or transfusion reactions.
Dermatologic diseases: Atopic dermatitis, bullous dermatitis herpetiformis, contact dermatitis, exfoliative erythroderma, mycosis fungoides, pemphigus, or severe erythema multiforme (Stevens-Johnson syndrome).
Endocrine disorders: Primary or secondary adrenocortical insufficiency (hydrocortisone or cortisone is the drug of choice), congenital adrenal hyperplasia, hypercalcemia associated with cancer, or nonsuppurative thyroiditis.
GI diseases: To tide the patient over a critical period of disease in Crohn disease or ulcerative colitis.
Hematologic disorders: Acquired (autoimmune) hemolytic anemia, Diamond-Blackfan anemia, pure red cell aplasia, select cases of secondary thrombocytopenia.
Neoplastic diseases: Palliative management of leukemias and lymphomas.
Nervous system: Acute exacerbations of multiple sclerosis; cerebral edema associated with primary or metastatic brain tumor or craniotomy. Note: Treatment guidelines recommend the use of high dose IV or oral methylprednisolone for acute exacerbations of multiple sclerosis (AAN [Scott 2011]; NICE 2014).
Ophthalmic diseases: Sympathetic ophthalmia, temporal arteritis, uveitis, and ocular inflammatory conditions unresponsive to topical corticosteroids.
Renal diseases: To induce diuresis or remission of proteinuria in idiopathic nephrotic syndrome or that is caused by lupus erythematosus.
Respiratory diseases: Berylliosis, fulminating or disseminated pulmonary tuberculosis when used concurrently with appropriate antituberculous chemotherapy, idiopathic eosinophilic pneumonias, symptomatic sarcoidosis.
Rheumatic disorders: As adjunctive therapy for short-term administration in acute gouty arthritis; acute rheumatic carditis; ankylosing spondylitis; psoriatic arthritis; RA, including juvenile RA; treatment of dermatomyositis, polymyositis, and systemic lupus erythematosus.
Miscellaneous: Trichinosis with neurologic or myocardial involvement; tuberculous meningitis with subarachnoid block or impending block when used with appropriate antituberculous chemotherapy.
Off Label Uses
The use of corticosteroids in the treatment of pericarditis remains controversial and dependent on the choice of steroid, dosing regimen, and route of administration. Current guidelines state that the use of intrapericardially administered corticosteroids is highly effective and circumvents common systemic adverse effects. Guidelines suggest this treatment should be restricted to certain types of pericarditis. At this time, intrapericardial administration of triamcinolone for autoreactive pericarditis has been shown to be an effective treatment in the prevention of recurrent symptoms and/or relapse of pericardial effusion. More clinical trials need to be conducted to determine whether intrapericardial administration of triamcinolone is effective for multiple types of pericarditis and to establish the best dose and/or dosing regimen for each type of pericarditis.
Hypersensitivity to triamcinolone or any component of the formulation; immune thrombocytopenia (formerly known as idiopathic thrombocytopenic purpura) (IM administration only).
Additional contraindication: Zilretta: Hypersensitivity to corticosteroids.
Documentation of allergenic cross-reactivity for corticosteroids is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.
Note: Aristospan Intra-Articular and Aristospan Intralesional have been discontinued in the US for more than 1 year.
Adjust dose depending upon condition being treated and response of patient. The lowest possible dose should be used to control the condition; when dose reduction is possible, the dose should be reduced gradually.
Acetonide (Kenalog-10): 1 mg Intralesional: Initial dose varies depending on the specific disease and lesion being treated; may be repeated at weekly or less frequent intervals; multiple sites may be injected if they are 1 cm or more apart
Hexacetonide (Aristospan 5 mg/mL): Intralesional, sublesional: Up to 0.5 mg/square inch of affected skin; range: 2 to 48 mg/day
Inflammatory/allergic conditions/other steroid-responsive systemic conditions: Acetonide (Kenalog-40): IM: Initial: 60 mg; adjust dose to a range of 40 to 80 mg. For patients with hay fever or pollen asthma who are not responding to pollen administration and other conventional therapy, a single injection of 40 mg to 100 mg per season may be given.
Multiple sclerosis (acute exacerbation):
Note: Treatment guidelines recommend the use of high dose IV or oral methylprednisolone for acute exacerbations of multiple sclerosis (AAN [Scott 2011]; NICE 2014).
Acetonide (Kenalog-40): IM: 160 mg daily for 1 week, followed by 64 mg every other day for 1 month.
Intra-articular (or similar injection as designated):
Acetonide: Intra-articular, intrabursal, tendon sheaths: Initial: Smaller joints: 2.5 to 5 mg, larger joints: 5 to 15 mg; may require up to 10 mg for small joints and up to 40 mg for large joints; maximum dose/treatment (several joints at one time): 80 mg
Zilretta only: Intra-articular: Single dose: 32 mg. Note: For osteoarthritis (OA) pain of the knee only (use for OA pain of shoulder and hip have not been evaluated); use is not suitable for small joints (eg, hand). Safety and efficacy of repeat administration has not been studied.
Hexacetonide (Aristospan 20 mg/mL): Intra-articular: Average dose: 2 to 20 mg; smaller joints (interphalangeal, metacarpophalangeal): 2 to 6 mg; large joints (knee, hip, shoulder): 10 to 20 mg. Frequency of injection into a single joint is every 3 to 4 weeks as necessary; to avoid possible joint destruction use as infrequently as possible.
IM: Acetonide (Kenalog-40): Initial: 60 mg; range: 2.5 to 100 mg/day
Pericarditis (off-label use): Intrapericardial (off-label route): 300 mg/m2 as a single dose (Maisch 2002) or 50 mg every 6 hours for 2 to 3 days (ESC [Maisch 2004]); may use in conjunction with oral colchicine therapy. Administration may be painful and appropriate analgesic premedication (eg, morphine) should be administered (Frasiolas 2010; Maisch 2002). Additional data may be necessary to further define the role of triamcinolone in this condition.
Refer to adult dosing.
Note: Aristospan Intra-Articular and Aristospan Intralesional have been discontinued in the US for more than 1 year.
Adjust dose depending upon condition being treated and response of patient. The lowest possible dose should be used to control the condition; when dose reduction is possible, the dose should be reduced gradually.
Acetonide (Kenalog-10): Intralesional: Children and Adolescents: Initial dose varies depending on the specific disease and lesion being treated; may be repeated at weekly or less frequent intervals; multiple sites may be injected if they are 1 cm or more apart
Hexacetonide (Aristospan 5 mg/mL): Intralesional, sublesional: Up to 0.5 mg/square inch of affected skin; initial range: 2 to 48 mg; frequency of dose is determined by clinical response
Inflammatory/allergic conditions/other steroid-responsive systemic conditions: Children and Adolescents:
Manufacturer's labeling: Acetonide (Kenolog-40): IM: Initial: 0.11 to 1.6 mg/kg/day (or 3.2 to 48 mg/m2/day) in 3 to 4 divided doses
Alternative dosing: Limited data available: Acetonide: Children 6 to 12 years: IM: 0.03 to 0.2 mg/kg/dose every 1 to 7 days (Kliegman, 2011)
Rheumatic conditions: Children and Adolescents: Intra-articular:
Acetonide: Initial: Smaller joints: 2.5 to 5 mg, larger joints: 5 to 15 mg; Up to 80 mg (total) has been given for single injections into several joints.
Hexacetonide (Aristospan 20 mg/mL): Average dose: 2 to 20 mg; small joints (interphalangeal, metacarpophalangeal): 2 to 6 mg; large joints (knee, hip, shoulder): 10 to 20 mg. Frequency of injection into a single joint is every 3 to 4 weeks as necessary; to avoid possible joint destruction use as infrequently as possible
Alternative dosing: Limited data available: Hexacetonide: Large joints (typically knees, ankles): 1 to 1.5 mg/kg/dose; maximum dose: 40 mg; doses greater than 1.5 mg/kg have not been associated with additional clinical benefit; similar dosing for the acetonide salt can be used; however, data show that the response is greater and lasts longer with hexacetonide (Bloom, 2011; Hashkes, 2005; Zulian, 2003; Zulian 2004)
Dosing: Renal Impairment
There are no dosage adjustments provided in the manufacturer's labeling; use with caution.
Dosing: Hepatic Impairment
There are no dosage adjustments provided in the manufacturer's labeling; use with caution.
Hexacetonide injectable suspension: Avoid diluents containing parabens, phenol, or other preservatives (may cause flocculation). Suspension for intralesional use may be diluted with lidocaine 1% or 2% (or similar local anesthetic), D5NS, D10NS, NS, or SWFI to a 1:1, 1:2, or 1:4 concentration. Solutions for intra-articular use, may be diluted with lidocaine 1% or 2% (or similar local anesthetic).
Intrapericardial (off-label route) administration: Triamcinolone hexacetonide dose should be diluted in at least 100 mL of warm (37°C) NS (Frasiolas 2010).
Shake well before use to ensure suspension is uniform. Inspect visually to ensure no clumping; administer immediately after withdrawal so settling does not occur in the syringe. Do not administer any product IV or via the epidural or intrathecal route.
Kenalog-10 injection: For intra-articular or intralesional administration only. When administered intralesionally, inject directly into the lesion (ie, intradermally or subcutaneously). One mL syringes with a 23- to 25-gauge needle are preferable for intralesional injections.
Kenalog-40 injection: For intra-articular, soft tissue or IM administration. When administered IM, inject deep into the gluteal muscle using a minimum needle length of 11/2 inches for adults. Obese patients may require a longer needle. Alternate sites for subsequent injections. Avoid IM injections into deltoid area.
Zilretta injection: For intra-articular administration only; do not administer IV, IM, SubQ, intrathecally, intraocularly, intradermally, or via epidural. Prepare suspension only using the diluent supplied in the kit (refer to manufacturer labeling for preparation instructions and administration techniques). Promptly inject after preparation. If needed, may store suspension in the vial ≤4 hours at ambient conditions; gently swirl vial to resuspend any settled microspheres prior to preparing syringe for injection. Aspiration of synovial fluid may be performed based on clinical judgment prior to administration.
Intrapericardial (off-label route): Triamcinolone hexacetonide: Instillation of triamcinolone suspension (diluted in 100 mL of warm [37°C] NS) may be administered as a slow injection over a 7F pigtail catheter introduced after pericardiocentesis; may be painful and appropriate analgesic premedication (eg, morphine) should be administered (Frasiolas 2010, Maisch 2002).
Hexacetonide: Dilute with a compatible solution prior to administration.
Aristospan (5 mg/mL): For intralesional or sublesional administration only; use a ≥23-gauge needle
Aristospan (20 mg/mL): For intra-articular and soft tissue administration only; use a ≥23-gauge needle
Ensure adequate intake of calcium and vitamins (or consider supplementation) in patients on medium-to-high doses of systemic corticosteroids.
Acetonide injectable suspension: Store at 20°C to 25°C (68°F to 77°F); avoid freezing. Protect from light.
Zilretta only: Store kit at 2°C to 8°C (36°F to 46°F). Do not freeze. If refrigeration is unavailable, may store unopened kit at ≤77°F (25°C) for ≤ 6 weeks. Do not store >77°F (25°C). May store reconstituted suspension in the vial ≤4 hours at ambient conditions.
Hexacetonide injectable suspension: Store at 20°C to 25°C (68°F to 77°F); avoid freezing. Protect from light. Diluted suspension stable up to 1 week.
Acetylcholinesterase Inhibitors: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Acetylcholinesterase Inhibitors. Increased muscular weakness may occur. Monitor therapy
Aldesleukin: Corticosteroids may diminish the antineoplastic effect of Aldesleukin. Avoid combination
Amphotericin B: Corticosteroids (Systemic) may enhance the hypokalemic effect of Amphotericin B. Monitor therapy
Amphotericin B: Corticosteroids (Orally Inhaled) may enhance the hypokalemic effect of Amphotericin B. Monitor therapy
Androgens: Corticosteroids (Systemic) may enhance the fluid-retaining effect of Androgens. Monitor therapy
Antidiabetic Agents: Hyperglycemia-Associated Agents may diminish the therapeutic effect of Antidiabetic Agents. Monitor therapy
Antihepaciviral Combination Products: May increase the serum concentration of Triamcinolone (Systemic). Monitor therapy
Aprepitant: May increase the serum concentration of Corticosteroids (Systemic). Management: No dose adjustment is needed for single 40 mg aprepitant doses. For other regimens, reduce oral dexamethasone or methylprednisolone doses by 50%, and IV methylprednisolone doses by 25%. Antiemetic regimens containing dexamethasone reflect this adjustment. Consider therapy modification
Axicabtagene Ciloleucel: Corticosteroids (Systemic) may diminish the therapeutic effect of Axicabtagene Ciloleucel. Management: Avoid use of corticosteroids as premedication before axicabtagene ciloleucel. Corticosteroids may, however, be required for treatment of cytokine release syndrome or neurologic toxicity. Consider therapy modification
BCG (Intravesical): Immunosuppressants may diminish the therapeutic effect of BCG (Intravesical). Avoid combination
Calcitriol (Systemic): Corticosteroids (Systemic) may diminish the therapeutic effect of Calcitriol (Systemic). Monitor therapy
Ceritinib: Corticosteroids may enhance the hyperglycemic effect of Ceritinib. Monitor therapy
Coccidioides immitis Skin Test: Immunosuppressants may diminish the diagnostic effect of Coccidioides immitis Skin Test. Monitor therapy
Corticorelin: Corticosteroids may diminish the therapeutic effect of Corticorelin. Specifically, the plasma ACTH response to corticorelin may be blunted by recent or current corticosteroid therapy. Monitor therapy
CYP3A4 Inducers (Strong): May decrease the serum concentration of Corticosteroids (Systemic). Monitor therapy
CYP3A4 Inhibitors (Strong): May increase the serum concentration of Corticosteroids (Systemic). Monitor therapy
Deferasirox: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased. Monitor therapy
Deferasirox: Corticosteroids may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased. Monitor therapy
Denosumab: May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased. Monitor therapy
Desirudin: Corticosteroids (Systemic) may enhance the anticoagulant effect of Desirudin. More specifically, corticosteroids may increase hemorrhagic risk during desirudin treatment. Management: Discontinue treatment with systemic corticosteroids prior to desirudin initiation. If concomitant use cannot be avoided, monitor patients receiving these combinations closely for clinical and laboratory evidence of excessive anticoagulation. Consider therapy modification
Desmopressin: Corticosteroids (Systemic) may enhance the hyponatremic effect of Desmopressin. Avoid combination
Desmopressin: Corticosteroids (Orally Inhaled) may enhance the hyponatremic effect of Desmopressin. Avoid combination
DilTIAZem: May increase the serum concentration of Corticosteroids (Systemic). Monitor therapy
Echinacea: May diminish the therapeutic effect of Immunosuppressants. Consider therapy modification
Estrogen Derivatives: May increase the serum concentration of Corticosteroids (Systemic). Monitor therapy
Fingolimod: Immunosuppressants may enhance the immunosuppressive effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and other immunosuppressants when possible. If combined, monitor patients closely for additive immunosuppressant effects (eg, infections). Consider therapy modification
Fosaprepitant: May increase the serum concentration of Corticosteroids (Systemic). The active metabolite aprepitant is likely responsible for this effect. Consider therapy modification
Hyaluronidase: Corticosteroids may diminish the therapeutic effect of Hyaluronidase. Management: Patients receiving corticosteroids (particularly at larger doses) may not experience the desired clinical response to standard doses of hyaluronidase. Larger doses of hyaluronidase may be required. Consider therapy modification
Indacaterol: May enhance the hypokalemic effect of Corticosteroids (Systemic). Monitor therapy
Indium 111 Capromab Pendetide: Corticosteroids (Systemic) may diminish the diagnostic effect of Indium 111 Capromab Pendetide. Avoid combination
Isoniazid: Corticosteroids (Systemic) may decrease the serum concentration of Isoniazid. Monitor therapy
Leflunomide: Immunosuppressants may enhance the adverse/toxic effect of Leflunomide. Specifically, the risk for hematologic toxicity such as pancytopenia, agranulocytosis, and/or thrombocytopenia may be increased. Management: Consider not using a leflunomide loading dose in patients receiving other immunosuppressants. Patients receiving both leflunomide and another immunosuppressant should be monitored for bone marrow suppression at least monthly. Consider therapy modification
Loop Diuretics: Corticosteroids (Systemic) may enhance the hypokalemic effect of Loop Diuretics. Monitor therapy
Loop Diuretics: Corticosteroids (Orally Inhaled) may enhance the hypokalemic effect of Loop Diuretics. Monitor therapy
Loxapine: Agents to Treat Airway Disease may enhance the adverse/toxic effect of Loxapine. More specifically, the use of Agents to Treat Airway Disease is likely a marker of patients who are likely at a greater risk for experiencing significant bronchospasm from use of inhaled loxapine. Management: This is specific to the Adasuve brand of loxapine, which is an inhaled formulation. This does not apply to non-inhaled formulations of loxapine. Avoid combination
Macimorelin: Corticosteroids (Systemic) may diminish the diagnostic effect of Macimorelin. Avoid combination
Mifamurtide: Corticosteroids (Systemic) may diminish the therapeutic effect of Mifamurtide. Avoid combination
MiFEPRIStone: May diminish the therapeutic effect of Corticosteroids (Systemic). MiFEPRIStone may increase the serum concentration of Corticosteroids (Systemic). Management: Avoid mifepristone in patients who require long-term corticosteroid treatment of serious illnesses or conditions (e.g., for immunosuppression following transplantation). Corticosteroid effects may be reduced by mifepristone treatment. Avoid combination
Mitotane: May decrease the serum concentration of Corticosteroids (Systemic). Consider therapy modification
Natalizumab: Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased. Avoid combination
Neuromuscular-Blocking Agents (Nondepolarizing): May enhance the adverse neuromuscular effect of Corticosteroids (Systemic). Increased muscle weakness, possibly progressing to polyneuropathies and myopathies, may occur. Consider therapy modification
Nicorandil: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nicorandil. Gastrointestinal perforation has been reported in association with this combination. Monitor therapy
Nivolumab: Immunosuppressants may diminish the therapeutic effect of Nivolumab. Consider therapy modification
Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective): Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective). Monitor therapy
Nonsteroidal Anti-Inflammatory Agents (Nonselective): Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents (Nonselective). Monitor therapy
Ocrelizumab: May enhance the immunosuppressive effect of Immunosuppressants. Monitor therapy
Pidotimod: Immunosuppressants may diminish the therapeutic effect of Pidotimod. Monitor therapy
Pimecrolimus: May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination
Quinolones: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Quinolones. Specifically, the risk of tendonitis and tendon rupture may be increased. Monitor therapy
Ritonavir: May enhance the adverse/toxic effect of Triamcinolone (Systemic). Specifically, risks of developing iatrogenic Cushing syndrome and secondary adrenal insufficiency may be increased. Ritonavir may increase the serum concentration of Triamcinolone (Systemic). Monitor therapy
Roflumilast: May enhance the immunosuppressive effect of Immunosuppressants. Consider therapy modification
Salicylates: May enhance the adverse/toxic effect of Corticosteroids (Systemic). These specifically include gastrointestinal ulceration and bleeding. Corticosteroids (Systemic) may decrease the serum concentration of Salicylates. Withdrawal of corticosteroids may result in salicylate toxicity. Monitor therapy
Sargramostim: Corticosteroids (Systemic) may enhance the therapeutic effect of Sargramostim. Specifically, corticosteroids may enhance the myeloproliferative effects of sargramostim. Monitor therapy
Sipuleucel-T: Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Monitor therapy
Tacrolimus (Systemic): Corticosteroids (Systemic) may decrease the serum concentration of Tacrolimus (Systemic). Conversely, when discontinuing corticosteroid therapy, tacrolimus concentrations may increase. Monitor therapy
Tacrolimus (Topical): May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination
Telaprevir: Corticosteroids (Systemic) may decrease the serum concentration of Telaprevir. Telaprevir may increase the serum concentration of Corticosteroids (Systemic). Management: Concurrent use of telaprevir and systemic corticosteroids is not recommended. When possible, consider alternatives. If used together, employ extra caution and monitor closely for excessive corticosteroid effects and diminished telaprevir effects. Consider therapy modification
Tertomotide: Immunosuppressants may diminish the therapeutic effect of Tertomotide. Monitor therapy
Thiazide and Thiazide-Like Diuretics: Corticosteroids (Systemic) may enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics. Monitor therapy
Thiazide and Thiazide-Like Diuretics: Corticosteroids (Orally Inhaled) may enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics. Monitor therapy
Tisagenlecleucel: Corticosteroids (Systemic) may diminish the therapeutic effect of Tisagenlecleucel. Management: Avoid use of corticosteroids as premedication or at any time during treatment with tisagenlecleucel, except in the case of life-threatening emergency (such as resistant cytokine release syndrome). Consider therapy modification
Tofacitinib: Immunosuppressants may enhance the immunosuppressive effect of Tofacitinib. Management: Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted, and this warning seems particularly focused on more potent immunosuppressants. Consider therapy modification
Trastuzumab: May enhance the neutropenic effect of Immunosuppressants. Monitor therapy
Urea Cycle Disorder Agents: Corticosteroids (Systemic) may diminish the therapeutic effect of Urea Cycle Disorder Agents. More specifically, Corticosteroids (Systemic) may increase protein catabolism and plasma ammonia concentrations, thereby increasing the doses of Urea Cycle Disorder Agents needed to maintain these concentrations in the target range. Monitor therapy
Vaccines (Inactivated): Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation. Consider therapy modification
Vaccines (Live): Corticosteroids (Systemic) may enhance the adverse/toxic effect of Vaccines (Live). Corticosteroids (Systemic) may diminish the therapeutic effect of Vaccines (Live). Management: Doses equivalent to less than 2 mg/kg or 20 mg per day of prednisone administered for less than 2 weeks are not considered sufficiently immunosuppressive to create vaccine safety concerns. Higher doses and longer durations should be avoided. Consider therapy modification
Warfarin: Corticosteroids (Systemic) may enhance the anticoagulant effect of Warfarin. Monitor therapy
1% to 10%:
Hematologic & oncologic: Bruise (2%)
Neuromuscular & skeletal: Joint swelling (3%)
Respiratory: Cough (2%), sinusitis (2%)
Frequency not defined. Most reactions listed are based on reports for other agents in this same pharmacologic class and may not be specifically reported for systemic triamcinolone:
Cardiovascular: Bradycardia, cardiac arrhythmia, cardiac failure, cardiomegaly, cerebrovascular accident, circulatory shock, edema, embolism (fat), hypertension, hypertrophic cardiomyopathy (premature infants), myocardial rupture (following recent myocardial infarction), syncope, tachycardia, thromboembolism, thrombophlebitis, vasculitis
Central nervous system: Arachnoiditis (intrathecal), depression, emotional lability, euphoria, headache, increased intracranial pressure, insomnia, malaise, meningitis (intrathecal), mood changes, neuritis, neuropathy, paraplegia, paresthesia, personality changes, pseudotumor cerebri (upon discontinuation), psychosis, quadriplegia, seizure, sensory disturbance (intrathecal), spinal cord infarction, vertigo
Gastrointestinal: Abdominal distention, carbohydrate intolerance, gastrointestinal disease (intrathecal), gastrointestinal hemorrhage, gastrointestinal perforation, hiccups, increased appetite, nausea, pancreatitis, peptic ulcer, ulcerative esophagitis
Genitourinary: Bladder dysfunction (intrathecal), spermatozoa disorder (motility altered)
Hematologic & oncologic: Petechiae, purpura
Hepatic: Hepatomegaly, increased liver enzymes
Hypersensitivity: Anaphylactoid reaction, anaphylaxis, angioedema
Infection: Increased susceptibility to infection, infection, sterile abscess
Local: Postinjection flare (intra-articular)
Ophthalmic: Blindness (periocular; rare), cataract, cortical blindness, exophthalmos, glaucoma, increased intraocular pressure, papilledema
Renal: Increased urine calcium excretion
Respiratory: Pulmonary edema
Miscellaneous: Wound healing impairment
Concerns related to adverse effects:
• Adrenal suppression: May cause hypercortisolism or suppression of hypothalamic-pituitary-adrenal (HPA) axis, particularly in younger children or in patients receiving high doses for prolonged periods. HPA axis suppression may lead to adrenal crisis. Withdrawal and discontinuation of a corticosteroid should be done slowly and carefully. Particular care is required when patients are transferred from systemic corticosteroids to inhaled products due to possible adrenal insufficiency or withdrawal from steroids, including an increase in allergic symptoms. Patients receiving >20 mg per day of prednisone (or equivalent) may be most susceptible. Fatalities have occurred due to adrenal insufficiency in asthmatic patients during and after transfer from systemic corticosteroids to aerosol steroids; aerosol steroids do not provide the systemic steroid needed to treat patients having trauma, surgery, or infections.
• Anaphylactoid reactions: Rare cases of anaphylactoid reactions have been observed in patients receiving corticosteroids. Cases of serious anaphylaxis, including death, have been reported with triamcinolone acetonide.
• Dermal changes: Atrophy at the injection site has been reported. Avoid IM deltoid injection; subcutaneous atrophy may occur.
• Immunosuppression: Prolonged use of corticosteroids may also increase the incidence of secondary infection, cause activation of latent infections, mask acute infection (including fungal infections), prolong or exacerbate viral infections, or limit response to killed or inactivated vaccines. Exposure to chickenpox or measles should be avoided; corticosteroids should not be used to treat ocular herpes simplex, cerebral malaria, fungal infections, or viral hepatitis. Close observation is required in patients with latent tuberculosis and/or TB reactivity; restrict use in active TB (only fulminating or disseminated TB in conjunction with antituberculosis treatment). Amebiasis should be ruled out in any patient with recent travel to tropic climates or unexplained diarrhea prior to initiation of corticosteroids. Use with extreme caution in patients with Strongyloides infections; hyperinfection, dissemination, and fatalities have occurred.
• Kaposi sarcoma: Prolonged treatment with corticosteroids has been associated with the development of Kaposi sarcoma (case reports); if noted, discontinuation of therapy should be considered (Goedert 2002).
• Myopathy: Acute myopathy has been reported with high-dose corticosteroids, usually in patients with neuromuscular transmission disorders or when given concomitantly with neuromuscular blocking agents; may involve ocular and/or respiratory muscles; monitor creatine kinase; recovery may be delayed.
• Psychiatric disturbances: Corticosteroid use may cause psychiatric disturbances, including euphoria, insomnia, mood swings, and personality changes to severe depression and frank psychotic manifestations. Preexisting psychiatric conditions may be exacerbated by corticosteroid use.
• Septic arthritis: May occur as a complication to intra-articular or soft tissue administration; institute appropriate antimicrobial therapy as required.
• Cardiovascular disease: Use with caution in patients with HF and/or hypertension; use has been associated with fluid retention, electrolyte disturbances, and hypertension. Use with caution following acute MI; corticosteroids have been associated with myocardial rupture.
• Diabetes: Use corticosteroids with caution in patients with diabetes mellitus; may alter glucose production/regulation leading to hyperglycemia.
• Gastrointestinal disease: Use with caution or avoid use in patients with GI diseases (diverticulosis, diverticulitis, fresh intestinal anastomoses, active or latent peptic ulcer, ulcerative colitis, abscess or other pyogenic infection) due to perforation risk.
• Head injury: Increased mortality was observed in patients receiving high-dose IV methylprednisolone; high-dose corticosteroids should not be used for the management of head injury.
• Hepatic impairment: Use with caution in patients with hepatic impairment, including cirrhosis; long-term use has been associated with fluid retention.
• Myasthenia gravis: Use with caution in patients with myasthenia gravis; exacerbation of symptoms has occurred, especially during initial treatment with corticosteroids.
• Ocular disease: Use with caution in patients with cataracts and/or glaucoma; increased intraocular pressure, open-angle glaucoma, and cataracts have occurred with prolonged use. Use with caution in patients with a history of ocular herpes simplex; corneal perforation has occurred; do not use in active ocular herpes simplex. Not recommended for the treatment of optic neuritis; may increase frequency of new episodes. Consider routine eye exams in chronic users.
• Osteoporosis: Use with caution in patients with osteoporosis; high doses and/or long-term use of corticosteroids have been associated with increased bone loss and osteoporotic fractures.
• Renal impairment: Use with caution in patients with renal impairment; fluid retention may occur.
• Seizure disorders: Use corticosteroids with caution in patients with a history of seizure disorder; seizures have been reported with adrenal crisis.
• Thyroid disease: Changes in thyroid status may necessitate dosage adjustments; metabolic clearance of corticosteroids increases in hyperthyroid patients and decreases in hypothyroid ones.
Concurrent drug therapy issues:
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
• Elderly: Use with caution in the elderly with the smallest possible effective dose for the shortest duration.
• Pediatric: May affect growth velocity; growth should be routinely monitored in pediatric patients.
Dosage form specific issues:
• Benzyl alcohol and derivatives: Some dosage forms may contain benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997], CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol with caution in neonates. See manufacturer's labeling.
• Polysorbate 80: Some dosage forms may contain polysorbate 80 (also known as Tweens). Hypersensitivity reactions, usually a delayed reaction, have been reported following exposure to pharmaceutical products containing polysorbate 80 in certain individuals (Isaksson 2002, Lucente 2000, Shelley 1995). Thrombocytopenia, ascites, pulmonary deterioration, and renal and hepatic failure have been reported in premature neonates after receiving parenteral products containing polysorbate 80 (Alade 1986, CDC 1984). See manufacturer's labeling.
• Appropriate administration: Administer products only via recommended route (depending on product used). Do not administer any triamcinolone product via the intrathecal route; serious adverse events, including fatalities, have been reported following intrathecal administration of corticosteroids.
• Discontinuation of therapy: Withdraw therapy with gradual tapering of dose.
• Epidural injection: Corticosteroids are not approved for epidural injection. Serious neurologic events (eg, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, stroke), some resulting in death, have been reported with epidural injection of corticosteroids, with and without use of fluoroscopy.
• Intra-articular injection: May result in damage to joint tissues. Avoid injection into an infected site; injection into a previously infected joint is not usually recommended. Injection into unstable joints is generally not recommended. Examine any joint fluid present to exclude a septic process.
• Stress: Patients may require higher doses when subject to stress (ie, trauma, surgery, severe infection).
Blood pressure, blood glucose, electrolytes; weight; intraocular pressure (use >6 weeks); bone mineral density; growth and development in children; HPA axis suppression
Pregnancy Risk Factor
Adverse events have been observed with corticosteroids in animal reproduction studies. Some studies have shown an association between first trimester systemic corticosteroid use and oral clefts (Park-Wyllie 2000, Pradat 2003). Systemic corticosteroids may also influence fetal growth (decreased birth weight); however, information is conflicting (Lunghi 2010). Hypoadrenalism may occur in newborns following maternal use of corticosteroids in pregnancy; monitor. When systemic corticosteroids are needed in pregnancy, it is generally recommended to use the lowest effective dose for the shortest duration of time, avoiding high doses during the first trimester (Leachman 2006, Lunghi 2010, Makol 2011, Østensen 2009).
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience nausea, vomiting, insomnia, agitation, or hair thinning. Have patient report immediately to prescriber signs of infection, signs of high blood sugar (confusion, fatigue, increased thirst, increased hunger, polyuria, flushing, fast breathing, or breath that smells like fruit), signs of Cushing's disease (weight gain in upper back or abdomen; moon face; severe headache; or slow healing), signs of adrenal gland problems (severe nausea, vomiting, severe dizziness, passing out, muscle weakness, severe fatigue, mood changes, lack of appetite, or weight loss), signs of low potassium (muscle pain or weakness, muscle cramps, or an abnormal heartbeat), severe abdominal pain, loss of strength and energy, irritability, tremors, tachycardia, confusion, sweating a lot, severe headache, dizziness, passing out, shortness of breath, excessive weight gain, swelling of arms or legs, vomiting blood, thrush, bone pain, joint pain, joint edema, vision changes, mood changes, behavioral changes, depression, menstrual changes, seizures, burning or numbness feeling, injection site irritation or edema, signs of skin changes (acne, stretch marks, slow healing, or hair growth), or black, tarry, or bloody stools (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.
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