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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
Index Terms
Generic Available
Yes: Cream, lotion, ointment, paste, powder
Canadian Brand Names
Pharmacologic Category
Pharmacologic Category Synonyms
Use: Labeled Indications
Nasal inhalation: Management of seasonal and perennial allergic rhinitis in patients ?6 years of age
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, 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
Pregnancy Considerations
There are no adequate and well-controlled studies in pregnant women, however, triamcinolone is teratogenic in animals; use during pregnancy with caution. Increased incidence of cleft palate, neonatal adrenal suppression, low birth weight, and cataracts in the infant has been reported following corticosteroid use during pregnancy. In general, the use of large amounts, or prolonged use, of topical corticosteroids during pregnancy should be avoided. In the mother, corticosteroids may increase calcium and potassium excretion, elevate blood pressure, and cause salt and water retention.
Lactation
Excretion in breast milk unknown/use caution
Breast-Feeding Considerations
It is not known if triamcinolone is excreted in breast milk, however, other corticosteroids are excreted. Prednisone and prednisolone are excreted in breast milk; the AAP considers them to be “usually compatible” with breast-feeding. Hypertension was reported in a nursing infant when a topical corticosteroid was applied to the nipples of the mother.
Contraindications
Hypersensitivity to triamcinolone or any component of the formulation; systemic fungal infections; serious infections (except septic shock or tuberculous meningitis); primary treatment of status asthmaticus; fungal, viral, or bacterial infections of the mouth or throat (oral topical formulation)
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.
•Delayed wound healing: Avoid nasal corticosteroid use in patients with recent nasal septal ulcers, nasal surgery or nasal trauma until healing has occurred.
• 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. Corticosteroids should not be used for cerebral malaria. Close observation is required in patients with latent tuberculosis and/or TB reactivity; restrict use in active TB (only in conjunction with antituberculosis treatment).
• 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; 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.
• 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. 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 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.
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: Injection suspension contains benzyl alcohol; benzyl alcohol has been associated with the "gasping syndrome" in neonates and low-birth-weight infants.
• Injection: Ocular effects: Intravitreal 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 intravitreal injection has not been demonstrated.
• 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
Systemic: Frequency not defined:
Cardiovascular: Angioedema, bradycardia, CHF, hypertension, myocardial rupture (following recent MI), thrombophlebitis, vasculitis
Central nervous system: Convulsions, depression, emotional instability, fever, headache, intracranial pressure increased, neuropathy, paresthesia, personality changes, vertigo
Dermatologic: Acne, allergic dermatitis, bruising, cutaneous atrophy, dry/scaly skin, ecchymoses, facial erythema, petechiae, photosensitivity, rash, striae, thin/fragile skin, wound healing impaired
Endocrine & metabolic: Adrenocortical/pituitary unresponsiveness (particularly during stress), carbohydrate tolerance decreased, cushingoid state, diabetes mellitus (manifestations of latent disease), fluid retention, growth suppression (children), hirsutism, hypokalemic alkalosis, menstrual irregularities, negative nitrogen balance, potassium loss, sodium retention
Gastrointestinal: Abdominal distention, bowel perforation, diarrhea, dyspepsia, nausea, oral Monilia (oral inhaler), pancreatitis, peptic ulcer, ulcerative esophagitis, weight gain
Hepatic: Hepatomegaly
Local: Skin atrophy (at the injection site)
Neuromuscular & skeletal: Calcinosis (following intra-articular or intralesional injection), Charcot-like arthropathy, femoral/humeral head aseptic necrosis, muscle mass decreased, muscle weakness, osteoporosis, pathologic fracture of long bones, steroid myopathy, tendon rupture, vertebral compression fractures
Ocular: Blindness (periocular injections), cataracts, intraocular pressure increased, exophthalmos, glaucoma, subcapsular cataract
Respiratory: Cough increased (nasal spray), epistaxis (nasal inhaler/spray), pharyngitis (nasal spray/oral inhaler), sinusitis (oral inhaler), voice alteration (oral inhaler)
Miscellaneous: Abnormal fat deposition (moon face), anaphylactoid reaction, anaphylaxis, diaphoresis increased, suppression to skin tests
Topical: Frequency not defined:
Dermatologic: Itching, allergic contact dermatitis, dryness, folliculitis, skin infection (secondary), itching, hypertrichosis, acneiform eruptions, hypopigmentation, skin maceration, skin atrophy, striae, miliaria, perioral dermatitis, atrophy of oral mucosa
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
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
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/toxic 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
Vaccines (Dead Organisms): Immunosuppressants may diminish the therapeutic effect of Vaccines (Dead Organisms). Risk C: Monitor therapy
Vaccines (Live Organisms): Immunosuppressants may enhance the adverse/toxic effect of Vaccines (Live Organisms). Vaccinal infections may develop. Immunosuppressants may also decrease therapeutic response to vaccines. 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
Store at room temperature; do not freeze.
Injection, suspension: Shake well prior to use.
Hexacetonide suspension: Diluted suspension stable ~1 week.
Topical spray: Avoid excessive heat.
Reconstitution
Injection, suspension: Hexacetonide: Avoid diluents containing parabens or preservatives (may cause flocculation). Suspension for intralesional use may be diluted with D5NS, D10NS 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: Vd: 99.5 L
Protein binding: ~68%
Time to peak: I.M.: 8-10 hours
Half-life elimination: Biologic: 18-36 hours
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
Intradermal: Adults: Initial: 1 mg
I.M.: Range: 2.5-60 mg/day
Children 6-12 years: Initial: 40 mg
Children >12 years and Adults: Initial: 60 mg
Hexacetonide: Adults:
Intralesional, sublesional: Up to 0.5 mg/square inch of affected skin
Intra-articular: Range: 2-20 mg
Triamcinolone Dosing
Acetonide
Hexacetonide
Intrasynovial
5-40 mg
Intralesional
1-30 mg (usually 1 mg per injection site); 10 mg/mL suspension usually used
Up to 0.5 mg/sq inch affected area
Sublesional
1-30 mg
Systemic I.M.
2.5-60 mg/dose (usual adult dose: 60 mg; may repeat with 20-100 mg dose when symptoms recur)
Intra-articular
2.5-40 mg
2-20 mg average
large joints
5-15 mg
10-20 mg
small joints
2.5-5 mg
2-6 mg
Tendon sheaths
2.5-10 mg
Intradermal
1 mg/site
Table has been converted to the following text.
Acetonide:
Intra-articular: Large joints: 5-15 mg; small joints: 2.5-5 mg
Intradermal: 1 mg per injection site
Intralesional or sublesional: 1-30 mg (usually 1 mg per injection site); 10 mg/mL suspension usually used
Intrasynovial: 2.5-40 mg
Systemic (I.M.): Usual adult dose: 60 mg; may repeat with 20-100 mg dose when symptoms recur
Tendon sheath: 2.5-10 mg
Hexacetonide:
Intra-articular: Large joints: 10-20 mg; small joints: 2-6 mg
Intralesional or sublesional: Up to 0.5 mg per square inch of affected area
Intranasal: Perennial allergic rhinitis, seasonal allergic rhinitis:
Nasal spray:
Children 6-11 years: 110 mcg/day as 1 spray in each nostril once daily.
Children ?12 years and Adults: 220 mcg/day as 2 sprays in each nostril once daily
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)
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: Apply thin film to affected areas 2-4 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.
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: Apply a thin film sparingly and avoid topical application on the face. Do not use on open skin or wounds. Do not occlude area unless directed.
Administration: Other
Avoid subcutaneous administration.
Dietary Considerations
May be taken with food to decrease GI distress. 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
Triamcinolone is a long-acting corticosteroid with minimal sodium-retaining potential.
Neuromuscular Effects: ICU-acquired paresis was recently studied in 5 ICUs (3 medical and 2 surgical ICUs) at 4 French hospitals. All ICU patients without pre-existing neuromuscular disease admitted from March 1999 through June 2000 were evaluated (De Jonghe B, 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 evaluable, 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 appear 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). For selected patients on long-term, high-dose, inhaled corticosteroid (ICS), give stress doses of hydrocortisone intravenously during the surgical period and reduce the dose rapidly within 24 hours after surgery (Expert Panel Report 3, 2007). Clinically important adrenal suppression has been reported in patients receiving high doses of an ICS, particularly children. Guidelines for glucocorticoid replacement during various surgical procedures have been published (Salem, 1994; Coursin, 2002).
Septic Shock: A recent randomized, double-blind, placebo controlled trial assessed whether low dose corticosteroid administration could improve 28-day survival in patients with septic shock and relative adrenal insufficiency. Relative adrenal insufficiency was defined as an inappropriate response to corticotropin administration (increase of serum cortisol of ?9 mcg/dL from baseline). Cortisol levels were drawn immediately before corticotropin administration and 30-60 minutes afterwards. Three hundred adult septic shock patients requiring mechanical ventilation and vasopressor support were randomized to either hydrocortisone (50 mg IVP every 6 hours) and fludrocortisone (50 mcg tablet daily via nasogastric tube) or matching placebos for 7 days. In patients who did not appropriately respond to corticotropin (nonresponders), there were significantly fewer deaths in the active treatment group. Vasopressor therapy was withdrawn more frequently in this subset of the active treatment group. Adverse events were similar in both groups. Patients who lack adrenal reserve and thus have relative adrenal insufficiency during the stress of septic shock may benefit from physiologic steroid replacement. However, there was a trend for increased mortality in patients who responded to the corticotropin test (increase serum cortisol >9 mcg/dL from baseline). These patients may not benefit from physiologic steroid replacement. Further study is required to better characterize the patient populations who may benefit.
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.
Aerosol for oral inhalation, as acetonide:
Azmacort®: 75 mcg per actuation (20 g) [240 actuations]
Aerosol, topical, as acetonide:
Kenalog®: 0.2 mg/2-second spray (63 g)
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)
Injection, suspension, as acetonide:
Kenalog-10®: 10 mg/mL (5 mL) [contains benzyl alcohol; not for I.V. or I.M. use]
Kenalog-40®: 40 mg/mL (1 mL, 5 mL, 10 mL) [contains benzyl alcohol; not for I.V. or intradermal use]
Triesence™: 40 mg/mL (1 mL) [contains polysorbate 80; not for I.V. use]
Injection, suspension, as hexacetonide:
Aristospan®: 5 mg/mL (5 mL); 20 mg/mL (1 mL, 5 mL) [contains benzyl alcohol; 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]
Suspension, intranasal, as acetonide [spray]:
Nasacort® AQ: 55 mcg/inhalation (16.5 g) [120 actuations]
Pricing: U.S. (www.drugstore.com)
Aerosol solution (Azmacort)
75 mcg/ACT (20): $145.23
Aerosol solution (Kenalog)
(63): $65.99
Aerosol solution (Nasacort AQ)
55 mcg/ACT (16.5): $89.99
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): $9.99
0.1% (15): $8.99
0.1% (80): $25.99
0.5% (15): $14.99
Paste (Triamcinolone Acetonide)
0.1% (5): $26.99
References
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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.
Murphy CM, Coonce SL, and Simon PA, “Treatment of Asthma in Children,” Clin Pharm, 1991, 10(9):685-703.
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
Lexi-Comp.com
Last full review/revision August 2008
Content last modified August 2008
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