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Medication Safety Issues

Sound-alike/look-alike issues:

Kenalog® may be confused with Ketalar®

Nasacort® may be confused with NasalCrom®

TAC (occasional abbreviation for triamcinolone) is an error-prone abbreviation (mistaken as tetracaine-adrenaline-cocaine)

Pronunciation

(trye am SIN oh lone)

U.S. Brand Names

• Aristospan®
• Azmacort®
• Kenalog-10®
• Kenalog-40®
• Kenalog®
• Nasacort® AQ
• Tri-Nasal® [DSC]
• Triderm®
• Triesence™
• Trivaris™
• Zytopic™

Index Terms

• Triamcinolone Acetonide, Aerosol
• Triamcinolone Acetonide, Parenteral
• Triamcinolone Diacetate, Oral
• Triamcinolone Diacetate, Parenteral
• Triamcinolone Hexacetonide
• Triamcinolone, Oral

Generic Available

Yes: Cream, lotion, ointment, paste, powder

Canadian Brand Names

• Aristospan®
• Kenalog®
• Kenalog® in Orabase
• Nasacort® AQ
• Oracort
• Triaderm
• Trinasal®

Pharmacologic Category

• Corticosteroid, Inhalant (Oral)
• Corticosteroid, Nasal
• Corticosteroid, Ophthalmic
• Corticosteroid, Systemic
• Corticosteroid, Topical

Pharmacologic Category Synonyms

• Inhaled Corticosteroid (Oral)
• Steroid, Inhalant (Oral)
• Nasal Corticosteroid
• Steroid, Nasal
• Ophthalmic Corticosteroid
• Steroid, Ophthalmic
• Steroid, Systemic
• Systemic Corticosteroid
• Steroid, Topical
• Topical Corticosteroid

Use: Labeled Indications

Intra-articular (soft tissue): Acute gouty arthritis, acute/subacute bursitis, acute tenosynovitis, epicondylitis, rheumatoid arthritis, synovitis of osteoarthritis

Intralesional: Alopecia areata, discoid lupus erythematosus, keloids, granuloma annulare lesions (localized hypertrophic, infiltrated, or inflammatory), lichen planus plaques, lichen simplex chronicus plaques, psoriatic plaques, necrobiosis lipoidica diabeticorum, cystic tumors of aponeurosis or tendon (ganglia)

Nasal inhalation: Management of seasonal and perennial allergic rhinitis

Ophthalmic: Intravitreal: treatment of sympathetic ophthalmia, temporal arteritis, uveitis, ocular inflammatory conditions unresponsive to topical corticosteroids

Triesence™: Visualization during vitrectomy

Oral inhalation: Control of bronchial asthma and related bronchospastic conditions

Oral topical: Adjunctive treatment and temporary relief of symptoms associated with oral inflammatory lesions and ulcerative lesions resulting from trauma

Systemic: Adrenocortical insufficiency, dermatologic diseases, endocrine disorders, gastrointestinal diseases, hematologic and neoplastic disorders, nervous system disorders, nephrotic syndrome, rheumatic disorders, allergic states, respiratory diseases, systemic lupus erythematosus (SLE), and other diseases requiring anti-inflammatory or immunosuppressive effects

Topical: Inflammatory dermatoses responsive to steroids

Use: Dental

Oral topical: Adjunctive treatment and temporary relief of symptoms associated with oral inflammatory lesions and ulcerative lesions resulting from trauma

Pregnancy Risk Factor

C/D (ophthalmic suspension)

Pregnancy Considerations

Triamcinolone was shown to be teratogenic following inhalation in animal studies and adverse events have been observed with corticosteroids in animal reproduction studies. Some studies have shown an association between first trimester corticosteroid use and oral clefts; adverse events in the fetus/neonate have been noted in case reports following large doses of systemic corticosteroids during pregnancy.

Lactation

Excretion in breast milk unknown/use caution

Breast-Feeding Considerations

Corticosteroids are excreted in human milk; information specific to triamcinolone has not been located.

Contraindications

Hypersensitivity to triamcinolone or any component of the formulation; systemic fungal infections; primary treatment of status asthmaticus or other acute episodes of asthma; fungal, viral, or bacterial infections of the mouth or throat (oral topical formulation); cerebral malaria; idiopathic thrombocytopenic purpura (I.M. injection)

Warnings/Precautions

Concerns related to adverse effects:

• Adrenal suppression: May cause hypercorticism 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.

• Bronchospasm: May occur with wheezing after inhalation; if this occurs stop steroid and treat with a fast-acting bronchodilator (eg, albuterol).

•Delayed wound healing: Avoid nasal corticosteroid use in patients with recent nasal septal ulcers, nasal surgery or nasal trauma until healing has occurred.

• Head injury: Increased mortality was observed in patients receiving high-dose I.V. methylprednisolone; high-dose corticosteroids should not be used for the management of head injury.

• Immunosuppression: Prolonged use of corticosteroids may also increase the incidence of secondary infection, mask acute infection (including fungal infections), prolong or exacerbate viral infections, or limit response to vaccines. Exposure to chickenpox should be avoided; corticosteroids should not be used to treat ocular herpes simplex, cerebral malaria, or viral hepatitis. Close observation is required in patients with latent tuberculosis and/or TB reactivity; restrict use in active TB (only in conjunction with antituberculosis treatment). Use with caution in patients with threadworm infection; may cause serious hyperinfection.

• Kaposi's sarcoma: Prolonged treatment with corticosteroids has been associated with the development of Kaposi's sarcoma (case reports); if noted, discontinuation of therapy should be considered.

• Myopathy: Acute myopathy has been reported with high dose corticosteroids, usually in patients with neuromuscular transmission disorders; may involve ocular and/or respiratory muscles; monitor creatine kinase; recovery may be delayed.

• Psychiatric disturbances: Corticosteroid use may cause psychiatric disturbances, including depression, euphoria, insomnia, mood swings, and personality changes. Pre-existing psychiatric conditions may be exacerbated by corticosteroid use.

Disease-related concerns:

• Asthma: Supplemental steroids (oral or parenteral) may be needed during stress or severe asthma attacks. Not to be used in status asthmaticus or for the relief of acute bronchospasm.

• Cardiovascular disease: Use with caution in patients with HF or hypertension; long-term use has been associated with fluid retention and hypertension.

• Diabetes: Use with caution in patients with diabetes mellitus; may alter glucose production/regulation leading to hyperglycemia.

• Gastrointestinal disease: Use with caution in patients with GI diseases (diverticulitis, peptic ulcer, ulcerative colitis) due to perforation risk.

• Head injury: Increased mortality was observed in patients receiving high-dose I.V. 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.

• Myocardial infarct (MI): Use with caution following acute MI; corticosteroids have been associated with myocardial rupture.

• 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. Risk is increased in patients receiving ophthalmic injection; monitor closely for increased intraocular pressure. Consider routine eye exams in chronic users. Do not use in patients with active ocular herpes simplex.

• 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 and hypertension may occur.

• Seizure disorders: Use 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.

• Tuberculosis: Restrict corticosteroid use to fulminating or disseminated tuberculosis; must be used in conjunction with appropriate tuberculosis regimen. Monitor closely in patients with latent tuberculosis.

Concurrent drug therapy issues:

• Immunizations: Patients should not be immunized with live, viral vaccines while receiving immunosuppressive doses of corticosteroids. The ability to respond to dead viral vaccines is unknown.

Special populations:

• Elderly: Because of the risk of adverse effects, systemic corticosteroids should be used cautiously in the elderly in the smallest possible effective dose for the shortest duration. Azmacort® (metered dose inhaler) comes with its own spacer device attached and may be easier to use in older patients.

• Pediatrics: Orally-inhaled and intranasal corticosteroids may cause a reduction in growth velocity in pediatric patients (~1 centimeter per year [range 0.3-1.8 cm per year] and related to dose and duration of exposure). To minimize the systemic effects of orally-inhaled and intranasal corticosteroids, each patient should be titrated to the lowest effective dose. Growth should be routinely monitored in pediatric patients.

Dosage form specific issues:

• High potency products: Avoid the use of high potency steroids on the face.

• Injection: Benzyl alcohol: Some injection suspension formulations contain benzyl alcohol; benzyl alcohol has been associated with the "gasping syndrome" in neonates and low-birth-weight infants.

• Injection: Ocular effects :Intravitreal (Triesence™, Trivaris™) injection has been associated with endophthalmitis and visual disturbances. Blindness has been reported following injection into nasal turbinates and intralesional injections into the head. Safety of intraturbinal, subconjunctival, subtenons, retrobulbar, or has not been demonstrated. Some formulations should not be administered intravitreally.

• Topical: Do not use occlusive dressings on weeping or exudative lesions and general caution with occlusive dressings should be observed; discontinue if skin irritation or contact dermatitis should occur; do not use in patients with decreased skin circulation.

• Topical (oral): Discontinue if local irritation or sensitization should develop. If significant regeneration or repair of oral tissues has not occurred in seven days, re-evaluation of the etiology of the oral lesion is advised.

Other warnings/precautions:

• Discontinuation of therapy: Withdraw systemic therapy with gradual tapering of dose. There have been reports of systemic corticosteroid withdrawal symptoms (eg, joint/muscle pain, lassitude, depression) when withdrawing oral inhalation therapy.

Adverse Reactions

Inhalation (nasal, oral):

>10%:

Central nervous system: Headache (2% to 51%)

Respiratory: Pharyngitis (5% to 25%)

1% to 10%:

Cardiovascular: Facial edema (1% to 3%)

Central nervous system: Pain (1% to 3%)

Dermatologic: Photosensitivity (1% to 3%), rash (1% to 3%)

Endocrine & metabolic: Dysmenorrhea (?2%)

Gastrointestinal: Taste perversion (5% to 8%), dyspepsia (3% to 5%), abdominal pain (1% to 5%), nausea (2% to 3%), diarrhea (1% to 3%), oral moniliasis (1% to 3%), toothache (1% to 3%), vomiting (1% to 3%), weight gain (1% to 3%), xerostomia (1% to 3%)

Genitourinary: Cystitis (1% to 3%), urinary tract infection (1% to 3%), vaginal moniliasis (1% to 3%)

Local: Nasal burning (?2%; transient), nasal stinging (?2%; transient)

Neuromuscular & skeletal: Back pain (2% to 8%), bursitis (1% to 3%), myalgia (1% to 3%), tenosynovitis (1% to 3%)

Ocular: Conjunctivitis (1% to 4%)

Otic: Otitis media (?2%)

Respiratory: Sinusitis (2% to 9%), cough (?8%), epistaxis (?5%), bronchitis (children 3%), chest congestion (1% to 3%), asthma (?2%), rhinitis (?2%)

Miscellaneous: Flu-like syndrome (2% to 9%), voice alteration (1% to 3%), allergic reaction (?2%), infection (?2%)

<1%, postmarketing, and/or case reports: Anaphylaxis, blood cortisol decreased, bone mineral density loss (rare; prolonged use), cataracts, dizziness, dry throat, dyspnea, fatigue, glaucoma, growth suppression, hoarseness, hypersensitivity, insomnia, intraocular pressure increased, nasal septum perforation, oral candidiasis, osteoporosis (rare; prolonged use), pruritus, sneezing, throat irritation, urticaria (rare), wheezing, wound healing impaired

Injection:

Frequency not defined; reactions reported with corticosteroid therapy in general:

Cardiovascular: Arrhythmia, bradycardia, cardiac arrest, cardiac enlargement, CHF, circulatory collapse, edema, hypertension, hypertrophic cardiomyopathy (premature infants), myocardial rupture (following recent MI), syncope, tachycardia, thromboembolism, vasculitis

Central nervous system: Arachnoiditis (I.T.), depression, emotional instability, euphoria, headache, insomnia, intracranial pressure increased, malaise, meningitis (I.T.), mood changes, neuritis, neuropathy, personality change, pseudotumor cerebri (with discontinuation), seizure, vertigo

Dermatologic: Abscess (sterile), acne, allergic dermatitis, angioedema, atrophy (cutaneous/subcutaneous), bruising, dry skin, erythema, hair thinning, hirsutism, hyper-/hypopigmentation, hypertrichosis, impaired wound healing, lupus erythematosus-like lesions, petechiae, purpura, rash, skin test suppression, striae, thin skin

Endocrine & metabolic: Carbohydrate intolerance, Cushingoid state, diabetes mellitus, fluid retention, glucose intolerance, growth suppression (children), hypokalemia, hypokalemic alkalosis, menstrual irregularities, negative nitrogen balance, sodium retention, sperm motility altered

Gastrointestinal: Abdominal distention, appetite increased, GI hemorrhage, GI perforation, nausea, pancreatitis, peptic ulcer, ulcerative esophagitis, weight gain

Hepatic: Hepatomegaly, liver function tests increased

Local: Thrombophlebitis

Neuromuscular & skeletal: Aseptic necrosis of femoral and humeral heads, calcinosis, Charcot-like arthropathy, fractures, joint tissue damage, muscle mass loss, myopathy, osteoporosis, parasthesia, tendon rupture, vertebral compression fractures, weakness

Ocular: Cataracts, exophthalmos, glaucoma, ocular pressure increased, papilledema

Renal: Glycosuria

Respiratory: Pulmonary edema

Miscellaneous: Abnormal fat deposits, anaphylactoid reaction, anaphylaxis, diaphoresis, hiccups, infection, moon face

Ophthalmic:

>10%: Ocular: Cataract progression (20% to 60%), intraocular pressure increased (20% to 60%)

1% to 10%: Ocular: ?2%: Blurred vision, conjunctival hemorrhage, discomfort (transient), endophthalmitis, glaucoma, hypopyon, inflammation, optic disc vascular disorder, retinal detachment, vitreous floaters, visual acuity decreased

<1%, postmarketing, and/or case reports: Exophthalmos

Topical:

Frequency not defined:

Dermatologic: Acneiform eruptions, allergic contact dermatitis, dryness, folliculitis,, hypertrichosis, hypopigmentation, itching, miliaria, perioral dermatitis, skin atrophy, skin infection (secondary), skin maceration, striae

Local: Burning, irritation

Drug Interactions

Acetylcholinesterase Inhibitors: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Acetylcholinesterase Inhibitors. Increased muscular weakness may occur. Risk C: Monitor therapy

Aminoglutethimide: May increase the metabolism of Corticosteroids (Systemic). Risk C: Monitor therapy

Amphotericin B: Corticosteroids (Systemic) may enhance the hypokalemic effect of Amphotericin B. Risk C: Monitor therapy

Amphotericin B: Corticosteroids (Orally Inhaled) may enhance the hypokalemic effect of Amphotericin B. Risk C: Monitor therapy

Antidiabetic Agents: Corticosteroids (Systemic) may diminish the hypoglycemic effect of Antidiabetic Agents. In some instances, corticosteroid-mediated HPA axis suppression has led to episodes of acute adrenal crisis, which may manifest as enhanced hypoglycemia, particularly in the setting of insulin or other antidiabetic agent use. Risk C: Monitor therapy

Antidiabetic Agents: Corticosteroids (Orally Inhaled) may diminish the hypoglycemic effect of Antidiabetic Agents. In some instances, corticosteroid-mediated HPA axis suppression has led to episodes of acute adrenal crisis, which may manifest as enhanced hypoglycemia, particularly in the setting of insulin or other antidiabetic agent use. Risk C: Monitor therapy

Antifungal Agents (Azole Derivatives, Systemic): May decrease the metabolism of Corticosteroids (Systemic). Risk C: Monitor therapy

Aprepitant: May increase the serum concentration of Corticosteroids (Systemic). Risk D: Consider therapy modification

Barbiturates: May increase the metabolism of Corticosteroids (Systemic). Risk C: Monitor therapy

Calcitriol: Corticosteroids (Systemic) may diminish the therapeutic effect of Calcitriol. Risk C: Monitor therapy

Calcium Channel Blockers (Nondihydropyridine): May decrease the metabolism of Corticosteroids (Systemic). Risk C: 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. Risk C: Monitor therapy

CycloSPORINE: Corticosteroids (Systemic) may increase the serum concentration of CycloSPORINE. CycloSPORINE may increase the serum concentration of Corticosteroids (Systemic). Risk C: Monitor therapy

Echinacea: May diminish the therapeutic effect of Immunosuppressants. Risk D: Consider therapy modification

Estrogen Derivatives: May increase the serum concentration of Corticosteroids (Systemic). Risk C: Monitor therapy

Fluconazole: May decrease the metabolism of Corticosteroids (Systemic). Risk C: Monitor therapy

Fosaprepitant: May increase the serum concentration of Corticosteroids (Systemic). The active metabolite aprepitant is likely responsible for this effect. Risk D: Consider therapy modification

Isoniazid: Corticosteroids (Systemic) may decrease the serum concentration of Isoniazid. Risk C: 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. Risk D: Consider therapy modification

Loop Diuretics: Corticosteroids (Systemic) may enhance the hypokalemic effect of Loop Diuretics. Risk C: Monitor therapy

Loop Diuretics: Corticosteroids (Orally Inhaled) may enhance the hypokalemic effect of Loop Diuretics. Risk C: Monitor therapy

Macrolide Antibiotics: May decrease the metabolism of Corticosteroids (Systemic). Exceptions: Azithromycin; Dirithromycin [Off Market]; Spiramycin. Risk D: Consider therapy modification

Mitotane: May decrease the serum concentration of Corticosteroids (Systemic). Risk D: Consider therapy modification

Natalizumab: Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased. Risk X: 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. Risk D: Consider therapy modification

NSAID (COX-2 Inhibitor): Corticosteroids (Systemic) may enhance the adverse/toxic effect of NSAID (COX-2 Inhibitor). Risk C: Monitor therapy

NSAID (Nonselective): Corticosteroids (Systemic) may enhance the adverse/toxic effect of NSAID (Nonselective). Risk C: Monitor therapy

Primidone: May increase the metabolism of Corticosteroids (Systemic). Risk C: Monitor therapy

Quinolone Antibiotics: May enhance the adverse/toxic effect of Corticosteroids (Systemic). Risk of tendon-related side effects, including tendonitis and rupture, may be enhanced. Risk C: Monitor therapy

Rifamycin Derivatives: May increase the metabolism of Corticosteroids (Systemic). Risk C: Monitor therapy

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. Risk C: Monitor therapy

Thiazide Diuretics: Corticosteroids (Systemic) may enhance the hypokalemic effect of Thiazide Diuretics. Risk C: Monitor therapy

Thiazide Diuretics: Corticosteroids (Orally Inhaled) may enhance the hypokalemic effect of Thiazide Diuretics. Risk C: Monitor therapy

Trastuzumab: May enhance the neutropenic effect of Immunosuppressants. Risk C: Monitor therapy

Vaccines (Inactivated): Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Risk C: Monitor therapy

Vaccines (Live): Immunosuppressants may enhance the adverse/toxic effect of Vaccines (Live). Vaccinial infections may develop. Immunosuppressants may diminish the therapeutic effect of Vaccines (Live). Risk X: Avoid combination

Warfarin: Corticosteroids (Systemic) may enhance the anticoagulant effect of Warfarin. Risk C: Monitor therapy

Ethanol/Nutrition/Herb Interactions

Ethanol: Avoid ethanol (may enhance gastric mucosal irritation).

Food: Triamcinolone interferes with calcium absorption.

Herb/Nutraceutical: Avoid cat's claw, echinacea (have immunostimulant properties).

Storage

Injection, suspension:

Acetonide injectable suspension:

Kenalog®: Store at 20°C to 25°C (68°F to 77°F); avoid freezing. Protect from light.

Triesence™: Store at 4°C to 25°C (39°F to 77°F); do not freeze. Protect from light.

Trivaris™: Store at 2°C to 8°C (36°F to 46°F); avoid freezing. Protect from light.

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.

Inhalation, oral: Store at controlled room temperature of 20°C to 25°C (68°F to 77°F); avoid excessive heat. Do not puncture.

Intranasal: Store at controlled room temperature of 20°C to 25°C (68°F to 77°F); do not freeze.

Topical:

Ointment: Store at room temperature.

Spray: Store at room temperature; avoid excessive heat.

Reconstitution

Hexacetonide injectable suspension: Avoid diluents containing parabens, phenol, or other preservatives (may cause flocculation). Suspension for intralesional use may be diluted with 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%.

Mechanism of Action

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

Pharmacodynamics/Kinetics

Duration: Oral: 8-12 hours

Absorption: Topical: Systemic

Distribution: V_d: 99.5 L

Protein binding: ~68%

Time to peak: I.M.: 8-10 hours

Half-life elimination: Biologic: 18-36 hours; Intravitreal: Nonvitrectomized patients: 13-24 days, Vitrectomized patients: ~3 days (based upon 1 patient)

Excretion: Urine (~40%); feces (~60%)

Dosage

The lowest possible dose should be used to control the condition; when dose reduction is possible, the dose should be reduced gradually. Parenteral dose is usually 1/3 to 1/2 the oral dose given every 12 hours. In life-threatening situations, parenteral doses larger than the oral dose may be needed.

Injection:

Acetonide:

Intra-articular, intrabursal, tendon sheaths: Adults: Initial: Smaller joints: 2.5-5 mg, larger joints: 5-15 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): 20-80 mg

Intradermal: Adults: Initial: 1 mg

I.M.: Range: 2.5-100 mg/day

Children: Initial: 0.11-1.6 mg/kg/day in 3-4 divided doses

Children 6-12 years: Initial: 40 mg

Children >12 years and Adults: Initial: 60 mg

Hay fever/pollen asthma: 40-100 mg as a single injection/season

Multiple sclerosis (acute exacerbation): 160 mg daily for 1 week, followed by 64 mg every other day for 1 month

Hexacetonide: Adults:

Intralesional, sublesional: Up to 0.5 mg/square inch of affected skin; range: 2-48 mg

Intra-articular: Average dose: 2-20 mg; smaller joints: 2-6 mg; larger joints: 10-20 mg. Frequency of injection into a single joint is every 3-4 weeks as necessary; to avoid possible joint destruction use as infrequently as possible.

Intranasal: Perennial allergic rhinitis, seasonal allergic rhinitis:

Nasal spray:

Children 2-5 years: 110 mcg/day as 1 spray in each nostril once daily (maximum: 110 mcg/day)

Children 6-11 years: Initial: 110 mcg/day as 1 spray in each nostril once daily; may increase to 220 mcg/day as 2 sprays in each nostril if response not adequate; once symptoms controlled may reduce to 110 mcg/day

Children ?12 years and Adults: 220 mcg/day as 2 sprays in each nostril once daily; once symptoms controlled reduce to 110 mcg/day

Nasal inhaler:

Children 6-11 years: Initial: 220 mcg/day as 2 sprays in each nostril once daily

Children ?12 years and Adults: Initial: 220 mcg/day as 2 sprays in each nostril once daily; may increase dose to 440 mcg/day (given once daily or divided and given 2 or 4 times/day)

Ophthalmic injection: Intravitreal: Children and Adults

Ocular disease: Initial: 4 mg as a single dose; additional doses may be given as needed over the course of treatment

Visualization during vitrectomy (Triesence™): 1-4 mg

Oral inhalation: Asthma:

Children 6-12 years: 75-150 mcg 3-4 times/day or 150-300 mcg twice daily; maximum dose: 900 mcg/day

Children >12 years and Adults: 150 mcg 3-4 times/day or 300 mcg twice daily; maximum dose: 1200 mcg/day

NIH Asthma Guidelines (NIH, 2007) (administer in divided doses twice daily):

Children: 5-11 years:

“Low” dose: 300-600 mcg/day

“Medium” dose: >600-900 mcg/day

“High” dose: >900 mcg/day

Children ?12 years and Adults:

“Low” dose: 300-750 mcg/day

“Medium” dose: >750-1500 mcg/day

“High” dose: >1500 mcg/day

Oral topical: Oral inflammatory lesions/ulcers: Press a small dab (about 1/4 inch) to the lesion until a thin film develops. A larger quantity may be required for coverage of some lesions. For optimal results use only enough to coat the lesion with a thin film; do not rub in.

Topical:

Cream, Ointment:

0.025%: Apply thin film to affected areas 2-4 times/day

0.1% or 0.5%: Apply thin film to affected areas 2-3 times/day

Spray: Apply to affected area 3-4 times/day

Dental Usual Dosing

Oral inflammatory lesions/ulcers: Adults: Oral topical: Press a small dab (about 1/4 inch) to the lesion until a thin film develops; a larger quantity may be required for coverage of some lesions. For optimal results, use only enough to coat the lesion with a thin film; do not rub in.

Administration: I.M.

Inject I.M. dose deep in large muscle mass, avoid deltoid.

Administration: Inhalation

Intranasal: Spray/inhaler: Shake well prior to use. Gently blow nose to clear nostrils.

Nasacort® AQ: Prime prior to first use, by shaking contents well and releasing 5 sprays into the air. If product is not used for more than 2 weeks, reprime with 1 spray.

Oral: Shake well prior to use. Rinse mouth and throat after using inhaler to prevent candidiasis. Use spacer device provided with Azmacort®. To prime inhaler prior to first use, shake inhaler, then press cannister to release 2 puffs. Inhaler will need to reprimed if not used for longer than 3 days.

Administration: Topical

Oral topical: Apply small dab to lesion until a thin film develops; do not rub in. Apply at bedtime or after meals if applications are needed throughout the day.

Topical:

Ointment: Apply a thin film sparingly. Do not use on open skin or wounds. Do not occlude area unless directed; if using occluding dressing, monitor for infection.

Spray: Avoid eyes and do not inhale if spraying near face. Occlusive dressing may be used if instructed; monitor for infection.

Administration: Other

Avoid subcutaneous administration.

Ophthalmic injection (intravitreal):

Triescence™: Not for I.V. use. Shake vial well prior to use. Administer under controlled aseptic conditions (eg, sterile gloves, sterile drape, sterile eyelid speculum). Adequate anesthesia and a broad-spectrum bactericidal agent should be administered prior to injection. Inject immediately after withdrawing from vial. If administration is required in the second eye, a new vial should be used. Do not use if agglomerated (clumpy or granular appearance).

Trivaris™: Can be administered intravitreal; not for I.V use. Bring to room temperature prior to administration. A 27 gauge 1/2-inch needle is recommended for intravitreal administration.

Monitoring Parameters

Ophthalmic injection (intravitreal): Following injection monitor for increased intraocular pressure and endophthalmitis; check for perfusion of optic nerve head immediately after injection, tonometry within 30 minutes, biomicroscopy between 2-7 days after injection.

Dietary Considerations

Ensure adequate intake of calcium and vitamins (or consider supplementation) in patients on medium-to-high doses of systemic corticosteroids.

Patient Education

This drug is not intended for use during an acute asthma attack or for the relief of a bronchospasm. May take up to 2 weeks until the full effectiveness is seen. Use exactly as directed; do not increase dose or discontinue abruptly without consulting prescriber. Take oral medication with or after meals. Avoid alcohol. Limit intake of caffeine or stimulants. Prescriber may recommend increased dietary vitamins, minerals, or iron. If you have diabetes, monitor glucose levels closely (antidiabetic medication may need to be adjusted). Inform prescriber if you are experiencing greater than normal levels of stress (medication may need adjustment). Some forms of this medication may cause GI upset (oral medication may be taken with meals to reduce GI upset; or small frequent meals and frequent mouth care may reduce GI upset). You may be more susceptible to infection (avoid crowds and exposure to infection). Report promptly excessive nervousness or sleep disturbances; any signs of infection (sore throat, unhealed injuries); excessive growth of body hair or loss of skin color; vision changes; excessive or sudden weight gain (>3 lb/week); swelling of face or extremities; respiratory difficulty; muscle weakness; change in color of stools (black or tarry) or persistent abdominal pain; or worsening of condition or failure to improve. Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to become pregnant. Consult prescriber if breast-feeding.

Aerosol: Shake gently before use. Use at regular intervals, no more frequently than directed. Not for use during acute asthmatic attack. Follow directions that accompany product. Rinse mouth and throat after use to prevent candidiasis. Do not use intranasal product if you have a nasal infection, nasal injury, or recent nasal surgery. If using two products, consult prescriber in which order to use the two products. Report unusual cough or spasm; persistent nasal bleeding, burning, or irritation; or worsening of condition.

Inhalation: Sit when using. Take deep breaths for 3-5 minutes, and clear nasal passages before administration (use decongestant as needed). Hold breath for 5-10 seconds after use, and wait 1-3 minutes between inhalations. Follow package insert instructions for use. Do not exceed maximum dosage. If also using inhaled bronchodilator, use before triamcinolone. Rinse mouth and throat after use to reduce aftertaste and prevent candidiasis.

Topical: For external use only. Not for eyes or mucous membranes or open wounds. Apply in very thin layer to occlusive dressing. Apply dressing to area being treated. Avoid prolonged or excessive use around sensitive tissues, genital, or rectal areas. Inform prescriber if condition worsens (swelling, redness, irritation, pain, open sores) or fails to improve.

Geriatric Considerations

Because of the risk of adverse effects, systemic corticosteroids should be used cautiously in the elderly, in the smallest possible dose, and for the shortest possible time. Azmacort® (metered dose inhaler) comes with its own spacer device attached and may be easier to use in older patients.

Additional Information

16 mg triamcinolone is equivalent to 100 mg cortisone (no mineralocorticoid activity).

Effects of inhaled/intranasal steroids on growth have been observed in the absence of laboratory evidence of HPA axis suppression, suggesting that growth velocity is a more sensitive indicator of systemic corticosteroid exposure in pediatric patients than some commonly used tests of HPA axis function. The long-term effects of this reduction in growth velocity associated with orally-inhaled and intranasal corticosteroids, including the impact on final adult height, are unknown. The potential for “catch up” growth following discontinuation of treatment with inhaled corticosteroids has not been adequately studied.

Anesthesia and Critical Care Concerns/Other Considerations

Clinical Pearls/Comments: Triamcinolone is a long-acting corticosteroid with minimal sodium-retaining potential.

Evidence-Based Information:

Neuromuscular Effects: ICU-acquired paresis was recently studied in five ICUs (three medical and two surgical ICUs) at four French hospitals. All ICU patients without pre-existing neuromuscular disease admitted from March 1999 through June 2000 were evaluated (de Jonghe, 2002). Each patient had to be mechanically ventilated for ?7 days and was screened daily for awakening. The first day the patient was considered awake was Study Day 1. Patients with severe muscle weakness on Study Day 7 were considered to have ICU-acquired paresis. Among the 95 patients who were evaluated, about 25% developed ICU-acquired paresis. Independent predictors included female gender, the number of days with ?2 organ dysfunction, and administration of corticosteroids. Further studies may be required to verify and characterize the association between the development of ICU-acquired paresis and use of corticosteroids. Concurrent use of a corticosteroid and muscle relaxant appears to increase the risk of certain ICU myopathies; avoid or administer the corticosteroid at the lowest dose possible.

Adrenal Insufficiency: Patients will often have steroid-induced adverse effects on glucose tolerance and lipid profiles. When discontinuing steroid therapy in patients on long-term steroid supplementation, it is important that the steroid therapy be discontinued gradually. Abrupt withdrawal may result in adrenal insufficiency with hypotension and hyperkalemia. Patients on long-term steroid supplementation will require higher corticosteroid doses when subject to stress (eg, trauma, surgery, severe infection). Guidelines for glucocorticoid replacement during various surgical procedures have been published (Coursin, 2002; Salem, 1994).

Cardiovascular Considerations

Inhaled steroid therapy, usually used for chronic obstructive lung disease, has the important advantage of having minimal systemic effects. The inhaled steroid, when administered appropriately, may be assumed to have pulmonary effects equivalent to about 10 mg of oral steroids but with minimal systemic consequences. Oral and intravenous steroid therapy in patients with heart failure should be administered cautiously with special attention given to signs and symptoms of fluid retention.

Dental Health: Effects on Dental Treatment

Key adverse event(s) related to dental treatment: Ulcerative esophagitis, perioral dermatitis, atrophy of oral mucosa, burning, irritation, and oral monilia (oral inhaler).

Dental Health: Vasoconstrictor/Local Anesthetic Precautions

No information available to require special precautions

Mental Health: Effects on Mental Status

Nervousness and insomnia are common; may cause drowsiness, delirium, euphoria, hallucinations, or mood swings

Mental Health: Effects on Psychiatric Treatment

Barbiturates may increase the metabolism of triamcinolone

Nursing: Physical Assessment/Monitoring

Assess other medications patient may be taking for effectiveness and interactions. Assess results of laboratory tests, therapeutic effectiveness, and adverse effects according to indications for therapy, dose, route (systemic or topical), and duration of therapy. With systemic administration, patients with diabetes should monitor glucose levels closely (corticosteroids may alter glucose levels). Assess knowledge/teach patient appropriate use, interventions to reduce side effects, and adverse symptoms to report. When used for long-term therapy (>10-14 days), do not discontinue abruptly; decrease dosage incrementally.

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Aerosol for oral inhalation, as acetonide:

Azmacort®: 75 mcg per actuation (20 g) [contains chlorofluorocarbon; 240 actuations]

Aerosol, topical, as acetonide:

Kenalog®: 0.2 mg/2-second spray (63 g) [contains dehydrated ethanol 10.3%]

Cream, as acetonide: 0.025% (15 g, 80 g, 454 g); 0.1% (15 g, 80 g, 454 g, 2270 g); 0.5% (15 g)

Triderm®: 0.1% (30 g, 85 g)

Zytopic™: 0.1% (85 g)

Injection, suspension, as acetonide:

Kenalog-10®: 10 mg/mL (5 mL) [contains benzyl alcohol, polysorbate 80; not for I.V. or I.M. use]

Kenalog-40®: 40 mg/mL (1 mL, 5 mL, 10 mL) [contains benzyl alcohol, polysorbate 80; not for I.V. or intradermal use]

Triesence™: 40 mg/mL (1 mL) [contains polysorbate 80; not for I.V. use]

Trivaris™: 80 mg/mL (0.1 mL) [preservative free; not for I.V. use; (for intra-articular, intramuscular, intravitreal use)]

Injection, suspension, as hexacetonide:

Aristospan®: 5 mg/mL (5 mL); 20 mg/mL (1 mL, 5 mL) [contains benzyl alcohol, polysorbate 80; not for I.V. use]

Lotion, as acetonide: 0.025% (60 mL); 0.1% (60 mL)

Ointment, topical, as acetonide: 0.025% (15 g, 80 g, 454 g); 0.05% (430 g); 0.1% (15 g, 80 g, 454 g); 0.5% (15 g)

Paste, oral, topical, as acetonide: 0.1% (5 g)

Powder, for prescription compounding, as acetonide [micronized]: Triamcinolone acetonide USP (5 g)

Solution, intranasal, as acetonide [spray]:

Tri-Nasal®: 50 mcg/inhalation (15 mL) [120 actuations] [DSC]

Suspension, intranasal, as acetonide [spray]:

Nasacort® AQ: 55 mcg/inhalation (16.5 g) [120 actuations]

Pricing: U.S. (www.drugstore.com)

Aerosol solution (Kenalog)

(63): $98.99

Aerosol solution (Nasacort AQ)

55 mcg/ACT (16.5): $108.74

Cream (Kenalog)

0.1% (15): $18.99

0.5% (20): $54.99

Cream (Triamcinolone Acetonide)

0.025% (15): $11.99

0.025% (80): $12.99

0.1% (15): $11.99

0.1% (80): $12.99

0.1% (453.6): $29.99

0.5% (15): $12.99

Lotion (Kenalog)

0.1% (60): $51.99

Lotion (Triamcinolone Acetonide)

0.025% (60): $40.99

Ointment (Triamcinolone Acetonide)

0.025% (80): $11.99

0.1% (15): $8.99

0.1% (80): $18.99

0.1% (454): $23.97

0.5% (15): $14.99

Paste (Triamcinolone Acetonide)

0.1% (5): $62.36

References

Abraham E and Evans T, “Corticosteroids and Septic Shock [editorial],” JAMA, 2002, 288(7):886-7.

American Academy of Orthopaedic Surgeons Clinical Practice Guidelines on the Treatment Of Osteoarthritis Of The Knee (Non-Arthroplasty). Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2008. Available at http://www.aaos.org/research/guidelines/oakguideline.pdf; last accessed July 3, 2009.

American Academy of Pediatrics Committee on Drugs: “Transfer of Drugs and Other Chemicals Into Human Milk,” Pediatrics, 2001, 108(3):776-89.

Annane D, Sebille V, Charpentier C, et al, “Effect of Treatment With Low Doses of Hydrocortisone and Fludrocortisone on Mortality in Patients With Septic Shock,” JAMA, 2002, 288(7):862-71.

Boot AM, Nauta J, Hokken-Koelega AC, et al, “Renal Transplantation and Osteoporosis,” Arch Dis Child, 1995, 72(6):502-6.

Bowman H and Lennard TW, “Immunosuppressive Drugs,” Br J Hosp Med, 1992, 48(9):570-3.

Cooper MS and Stewart PM, “Corticosteroid Insufficiency in Acutely Ill Patients,” N Engl J Med, 2003, 348(8):727-34.

Coursin DB and Wood KE, “Corticosteroid Supplementation for Adrenal Insufficiency,” JAMA, 2002, 287(2):236-40.

de Jonghe B, Sharshar T, Lefaucheur JP, et al, “Paresis Acquired in the Intensive Care Unit. A Prospective Multicenter Study,” JAMA, 2002, 288(22):2859-67.

Expert Panel Report 3, “Guidelines for the Diagnosis and Management of Asthma,” Clinical Practice Guidelines, National Institutes of Health, National Heart, Lung, and Blood Institute, NIH Publication No. 08-4051, prepublication 2007. Available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Frey BM and Frey FJ, “Clinical Pharmacokinetics of Prednisone and Prednisolone,” Clin Pharmacokinet, 1990, 19(2):126-46.

Gamsu HR, Mullinger BM, Donnai P, et al, “Antenatal Administration of Betamethasone to Prevent Respiratory Distress Syndrome in Preterm Infants: Report of a UK Multicentre Trial,” Br J Obstet Gynaecol, 1989, 96(4):401-10.

Goedert JJ, Vitale F, Lauria C, et al, “Risk Factors for Classical Kaposi's Sarcoma,” J Natl Cancer Inst, 2002, 94(22):1712-8.

Grotz WH, Mundinger FA, Gugel B, et al, “Bone Mineral Density After Kidney Transplantation: A Cross-Sectional Study in 190-Graft Recipients Up to 20 Years After Transplantation,” Transplantation, 1995, 59(7):982-6.

Gutin PH, “Corticosteroid Therapy in Patients With Brain Tumors,” Natl Cancer Inst Monogr, 1977, 46:151-6.

Hotchkiss RS and Karl IE, “The Pathophysiology and Treatment of Sepsis,” N Engl J Med, 2003, 348(2):138-50.

Kimberly RP, “Glucocorticoids,” Curr Opin Rheumatol, 1994, 6(3):273-80.

Liggins GC and Howie RN, “A Controlled Trial of Antepartum Glucocorticoid Treatment of Respiratory Distress Syndrome in Premature Infants,” Pediatrics, 1972, 50:515-25.

Lowenthal RM and Jestrimski KW, “Corticosteroid Drugs: Their Role in Oncological Practice,” Med J Aust, 1986, 144(2):81-5.

McGee S and Hirschmann J, “Use of Corticosteroids in Treating Infectious Diseases,” Arch Intern Med, 2008, 168(10):1034-46.

Murphy CM, Coonce SL, and Simon PA, “Treatment of Asthma in Children,” Clin Pharm, 1991, 10(9):685-703.

Ostensen M, “Optimisation of Antirheumatic Drug Treatment in Pregnancy,” Clin Pharmacokinet, 1994, 27(6):486-503.

Pradat P, Robert-Gnansia E, Di Tanna GL, et al, “First Trimester Exposure to Corticosteroids and Oral Clefts,” Birth Defects Res A Clin Mol Teratol, 2003, 67(12):968-70.

Reed B, “Dermatologic Drugs, Pregnancy, and Lactation. A Conservative Guide,” Arch Dermatol, 1997, 133:894-8.

Report of a Workshop by the British Association for Paediatric Nephrology and Research Unit, Royal College of Physicians, “Consensus Statement on Management and Audit Potential for Steroid Responsive Nephrotic Syndrome,” Arch Dis Child, 1994, 70(2):151-7.

Salem M, Tainsh RE Jr, Bromberg J, et al, “Perioperative Glucocorticoid Coverage. A Reassessment 42 Years After Emergence of a Problem,” Ann Surg, 1994, 219(4):416-25.

Todd GR, Acerini CL, Buck JJ, et al, "Acute Adrenal Crisis in Asthmatics Treated With High-Dose Fluticasone Propionate," Eur Respir J, 2002, 19(6):1207-9.

Todd GR, Acerini CL, Ross-Russell R, et al, "Survey of Adrenal Crisis Associated With Inhaled Corticosteroids in the United Kingdom," Arch Dis Child, 2002, 87(6):457-61.

International Brand Names

• Adcortyl (GB, IE)
• Aristocort (BB, BM, BS, BZ, GY, JM, PR, SR, TT)
• Aristocort A (MY)
• Azmacort (BR, PK, PL)
• Delphicort (AT, DE)
• Dermacort (HK, MY)
• Ftorocort (BB, BM, BS, BZ, GY, JM, PR, SR, TT)
• Intralon (MX)
• Kanolone (MY)
• Kemzid (HK)
• Kenacort (AE, AR, BE, BH, CH, CY, EG, ET, FR, ID, IL, IN, IQ, IR, IT, JO, KE, KW, LB, LU, LY, NL, OM, PH, QA, SA, SE, SY, TW, TZ, UG, UY, VE, YE)
• Kenacort A (CL, CO)
• Kenacort E (PE)
• Kenacort IM (CO)
• Kenacort T (FI, NO)
• Kenacort T Munnsalve (NO)
• Kenacort-A (AU, CN, HK, MY, PE)
• Kenalog (DK, PK, PL)
• Kenalog in Orabase (AU, BF, BJ, CI, GH, GM, GN, LR, MA, ML, MR, MU, MW, MY, NE, NG, NZ, SC, SD, SL, SN, TN, ZA, ZM, ZW)
• Keno (SG)
• Ledercort (GB, IN, IT, KP, LU, NL, PY, SE)
• Metoral (MY)
• Nasacort (BR, CN, ES, FI, GR, NO)
• Nasacort AQ (BF, BG, BJ, CI, CO, CR, CZ, DO, GH, GM, GN, GT, HK, HN, LR, MA, ML, MR, MU, MW, MX, MY, NE, NG, NI, PA, PE, SC, SD, SL, SN, SV, TN, ZA, ZM, ZW)
• Nasocor AQ (BF, BJ, CI, GH, GM, GN, LR, MA, ML, MR, MU, MW, NE, NG, SC, SD, SL, SN, TN, ZA, ZM, ZW)
• Nincort (CL)
• Oracort (NZ)
• Oramedy (HK, SG)
• Orrepaste (MY)
• Polcortolon [compr.] (PL)
• Polcortolone (HU)
• Shincort (HK, MY, SG)
• Simacort (TH)
• Sterocort (IL)
• Telnase (AU)
• Tracinone (KP)
• Triam-Denk (HK)
• Tricort (FI, TW)
• Tricortone (AU)
• Trigon (ES)
• Trinolon (ID)
• Volon (AT, DE)

Lexi-Comp.com

Last full review/revision September 2009

Content last modified September 2009