triamcinolone

Triamcinolone is a synthetic corticosteroid drug used to treat inflammatory conditions that affect the skin, joints, and internal organs. Triamcinolone is a corticosteroid analog with chemical structure similar to the naturally occurring corticosteroid produced by the cortical region of the adrenal gland.

Triamcinolone is a potent anti-inflammatory and immunomodulating drug used to treat acute systemic inflammations from various conditions including autoimmune disorders.

Triamcinolone inhibits inflammatory signals and synthesis and release of inflammatory substances. Triamcinolone binds to and activates glucocorticoid receptors on cell membranes and produces multiple anti-inflammatory processes:

• Inhibits the activity of phospholipase A2, an enzyme that induces the release of arachidonic acid, a substance that initiates the inflammatory process with the synthesis of inflammatory substances such as prostaglandins and leukotrienes
• Reduces capillary permeability to prevent the leakage of inflammatory cells and proteins (cytokines) into the inflammation site
• Prevents migration and aggregation of polymorphonuclear leukocytes (PMN), types of white cells such as neutrophils, eosinophils and basophils that release inflammatory substances
• Stabilizes the membranes of leukocyte lysosomes, the organelles inside the leukocytes that contain destructive enzymes
• Prevents migration of fibroblasts, cells that form an extracellular matrix, the supportive structure of all tissue, and prevents scar tissue formation

Triamcinolone is typically administered as injections into joints (intraarticular), skin lesions (intralesional), or into the muscle (intramuscular) for severe systemic inflammations when oral therapy is not feasible. Uses of triamcinolone include:

Intraarticular:

• Joint disorders: Gouty arthritis, acute and subacute bursitis, acute nonspecific tenosynovitis, epicondylitis, rheumatoid arthritis, and synovitis of osteoarthritis

Intralesional:

• Skin disorders: Discoid lupus erythematosus, alopecia areata, keloids, localized hypertrophic, infiltrated, inflammatory lesions of granuloma annulare, lichen planus, lichen simplex chronicus (neurodermatitis), psoriatic plaques, and necrobiosis lipoidica diabeticorum

Intramuscular:

• Severe allergic states: Asthma, atopic dermatitis, contact dermatitis, drug hypersensitivity reactions, perennial or seasonal allergic rhinitis, serum sickness, and transfusion reactions
• Dermatologic diseases: Bullous dermatitis herpetiformis, exfoliative erythroderma, mycosis fungoides, pemphigus, and severe erythema multiforme (Stevens-Johnson syndrome)
• Gastrointestinal conditions: Regional enteritis and ulcerative colitis
• Endocrine disorders: Primary or secondary adrenocortical insufficiency (not the first choice), congenital adrenal hyperplasia, hypercalcemia associated with cancer, and nonsuppurative thyroiditis
• Blood disorders: Acquired (autoimmune) hemolytic anemia, Diamond-Blackfan anemia, pure red cell aplasia, and selected cases of secondary thrombocytopenia
• Rheumatic disorders: As adjunctive therapy for short-term to tide over an acute episode in acute gouty arthritis; acute rheumatic carditis, ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, including juvenile rheumatoid arthritis, dermatomyositis, polymyositis, and systemic lupus erythematosus
• Respiratory diseases: Berylliosis, fulminating or disseminated pulmonary tuberculosis concurrently with appropriate antituberculous chemotherapy, idiopathic eosinophilic pneumonias, and symptomatic sarcoidosis
• Kidney diseases: To promote urination and remission of protein in urine (proteinuria) associated with idiopathic nephrotic syndrome or lupus erythematosus
• Nervous system disorders: Acute exacerbations of multiple sclerosis, and cerebral edema associated with primary or metastatic brain tumor or craniotomy
• Cancers: Palliative management of leukemias and lymphomas
• Ophthalmic conditions: Sympathetic ophthalmia, temporal arteritis, uveitis, and ocular inflammatory conditions unresponsive to topical corticosteroids
• Others: Trichinosis with neurologic or myocardial involvement, and tuberculous meningitis with subarachnoid block or impending block with appropriate antituberculous chemotherapy

• Triamcinolone injectable suspension should be administered only as intraarticular or intramuscular (IM) injections. Do not use for intravenous (IV), intradermal, subcutaneous (SC), intraocular, epidural, or intrathecal injections. Epidural and intrathecal injections can cause serious neurological side effects including paralysis and stroke.
• Do not administer to patients who are hypersensitive to triamcinolone or any of its components.
• Do not use IM corticosteroid for idiopathic thrombocytopenic purpura.
• Do not use triamcinolone for cerebral malaria.
• Do not use in the presence of systemic fungal infection, except as intra-articular injection for localized joint conditions.
• Do not administer to newborns. Triamcinolone formulations contain benzyl alcohol which has been associated with potentially fatal toxicity (gasping syndrome) in newborns.
• Patients receiving immunosuppressive doses of corticosteroids should not take live or live, attenuated vaccines.
• Corticosteroids may increase blood pressure, salt and water retention, and potassium excretion. Monitor for signs or symptoms such as edema, weight gain, and imbalance in serum electrolytes, in congestive heart failure or hypertensive patients.
• Corticosteroids can cause reversible suppression of hypothalamic-pituitary-adrenal axis, and potential for adrenal sufficiency after discontinuation, lasting for months. Institute corticosteroid replacement therapy in situations of stress during that period.
• Corticosteroids can cause new onset or exacerbation of increased intraocular pressure. Monitor patients.
• There have been rare cases of anaphylaxis resulting in death. Exercise caution.
• If the IM injection is not given deep into the muscle, it can cause skin atrophy. Avoid the deltoid region and administer in the gluteal region instead.
• Corticosteroids use can cause bone loss, use with caution in patients with osteoporosis.
• Corticosteroids may cause mood and behavioral disturbances, caution the patient, family and caregivers.
• Prolonged use of corticosteroids may increase the risk of secondary infection, activate latent infections, mask acute infection, prolong or exacerbate viral infections, or limit response to killed or inactivated vaccines.
• Do not use to treat ocular herpes simplex, cerebral malaria, fungal infections, viral hepatitis or active tuberculosis (TB). Monitor patients with latent TB.
• Do not use in the management of head injury, increased mortality has been reported in patients receiving high-dose IV methylprednisolone to manage head injuries.
• Prolonged use of corticosteroids is associated with development of Kaposi sarcoma, consider discontinuing therapy.
• Use with caution in gastrointestinal disease because of perforation risk.
• Use with caution in myasthenia gravis, may exacerbate symptoms.
• Acute myopathy has been reported with high-dose corticosteroids given concomitantly with neuromuscular blocking agents or in patients with neuromuscular transmission disorders. It may involve ocular and/or respiratory muscles, monitor creatinine kinase.
• Use with caution in kidney function impairment, may cause fluid retention.
• Use with caution in patients with a history of seizure disorder, seizures have been reported with adrenal crisis.
• Changes in thyroid status may necessitate dosage adjustments.
• Septic arthritis may occur as a complication to intra-articular or soft tissues manifestation; institute appropriate antibacterial therapy as necessary.
• Corticosteroid use is associated with psychiatric disturbances and exacerbation of pre-existing psychiatric conditions.

Common side effects of triamcinolone include:

• Joint swelling
• Bruises (contusions)
• Cough
• Sinus inflammation (sinusitis)
• Irregular heart rhythm (cardiac arrhythmia)
• Slow or rapid heart rate (bradycardia or tachycardia)
• Heart enlargement (cardiomegaly)
• High blood pressure (hypertension)
• Cardiac failure
• Heart muscle rupture following recent heart attack
• Thickened heart muscle (hypertrophic cardiomyopathy) in premature infants
• Cerebrovascular accident
• Circulatory shock
• Blood vessel inflammation (vasculitis)
• Blood clot block in blood vessels (thromboembolism)
• Vein inflammation with blood clots (thrombophlebitis)
• Fat embolism
• Fainting (syncope)
• Swelling (edema)
• Fluid retention
• Sodium retention
• Potassium loss
• High alkalinity of body fluids with low potassium (hypokalemic alkalosis)
• Negative nitrogen balance due to protein breakdown
• Decreased carbohydrate and glucose tolerance
• Manifestations of latent diabetes mellitus
• Excess sugar in urine (glycosuria)
• Increased requirements for insulin or medications for diabetes
• Increased susceptibility to infection
• Infection
• Nausea
• Hiccups
• Abdominal distention
• Change in bowel habits
• Peptic ulcer
• Ulcerative esophagitis
• Gastrointestinal (GI) hemorrhage
• GI perforation
• Increased appetite
• Inflammation of the pancreas (pancreatitis)
• Liver enlargement (hepatomegaly)
• Elevated liver enzymes
• Bladder dysfunction
• Aseptic tissue death (necrosis) of femoral and humeral heads
• Calcium deposits in the skin tissue (calcinosis) after intraarticular or intralesional use
• Loss of muscle mass
• Muscle weakness
• Steroid muscle disease (myopathy)
• Tendon rupture 
• Post injection flare (following intra-articular use)
• Joint disease (arthropathy)
• Brittle bones (osteoporosis)
• Fracture of long bones
• Vertebral compression fractures
• Development of cushingoid state with symptoms such as:
  • Moon face
  • Abnormal fat deposits
  • Weight gain around the midsection and upper back
• Menstrual irregularities
• Postmenopausal vaginal hemorrhage
• Decrease in sperm quantity and motility
• Male pattern hair growth in women (hirsutism)
• Secondary adrenocortical and pituitary unresponsiveness (particularly in times of stress, as in trauma, surgery, or illness)
• Suppression of growth in pediatric patients
• Skin reactions such as:
  • Acne
  • Rash
  • Hives (urticaria)
  • Dry scaly skin
  • Thin fragile skin
  • Redness (erythema)
  • Allergic dermatitis
  • Skin tissue loss (cutaneous and subcutaneous atrophy)
  • Discoloration and round spots (ecchymoses and petechiae)
  • Purple spots (purpura)
  • Stretch marks (striae)
  • Lupus erythematosus-like lesions
  • Changes in pigmentation (hyperpigmentation or hypopigmentation)
  • Impaired wound healing
  • Increased sweating

Suppressed reactions to skin tests

• Thinning scalp hair
• Hypersensitivity reactions including:
  • Swelling under the skin and mucous membrane (angioedema)
  • Severe allergic reaction (anaphylaxis)
• Feeling unwell (malaise)
• Headache
• Vertigo
• Increased intracranial pressure (pseudotumor cerebri)
• Nerve inflammation (neuritis)
• Nerve disease (neuropathy)
• Numbness and tingling (paresthesia)
• Convulsions
• Depression
• Euphoria
• Emotional instability
• Mood swings
• Personality changes
• Psychiatric disorders
• Insomnia

Call your doctor immediately if you experience any of the following symptoms or serious side effects while using this drug:

• Serious heart symptoms include fast or pounding heartbeats, fluttering in your chest, shortness of breath, and sudden dizziness;
• Severe headache, confusion, slurred speech, severe weakness, vomiting, loss of coordination, feeling unsteady;
• Severe nervous system reaction with very stiff muscles, high fever, sweating, confusion, fast or uneven heartbeats, tremors, and feeling like you might pass out; or
• Serious eye symptoms include blurred vision, tunnel vision, eye pain or swelling, or seeing halos around lights.

This is not a complete list of all side effects or adverse reactions that may occur from the use of this drug. Call your doctor for medical advice about serious side effects or adverse reactions. You may also report side effects or health problems to the FDA at 1-800-FDA-1088.

Injectable Suspension

• 10 mg/mL (Kenalog-10; intralesional or intra-articular administration)
• 40 mg/mL (Kenalog-40; IM or intra-articular administration)
• 80 mg/mL (Kenalog-40; IM or intra-articular administration)

Injectable, Powder for Reconstitution

• 32 mg/single-dose vial (Zilretta)
• When reconstituted, forms an extended-release suspension

Adult:

Rheumatic or Arthritic Disorders

• Treatment of rheumatic or arthritic disorders
• Kenalog-40: 60 mg intramuscular (IM) every 6 weeks; may be supplemented by additional 20-100 mg IM as needed
• Intra-articular/intrasynovial/soft-tissue injection (Kenalog-40): Large joints, 15-40 mg; small joints/tendon sheath inflammation, 2.5-10 mg
• Intra-articular injection (Kenalog-10): Large joints, 5-15 mg; small joints, 2.5-5 mg; single injections into several joints, up to a total of 20 mg or more have been given

Dermatoses

• Indicated for treatment of steroid-responsive dermatoses
• Intralesional injection (Kenalog-10): 1 mg per injection site 1 or more times weekly; not to exceed 30 mg/day
• Kenalog-10: Initial dose varies intralesional injection depending on 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

Inflammatory and Allergic Systemic Conditions

• Kenalog-40 or Kenalog-80: 60 mg IM single injection; adjust dose to a range of 40-80 mg
• For patients with hay fever or pollen asthma who are not responding to pollen administration and other conventional therapy, a single injection of 40-100 mg per season may be given

Multiple Sclerosis

• Kenalog-40 or Kenalog-80: 160 mg IM every day for 1 week, followed by 64 mg every other day for 1 month

Osteoarthritis (Zilretta)

• Indicated for management of osteoarthritis knee pain in adults
• Zilretta: 32 mg as a single intra-articular injection in the knee; not intended for repeat administration

Dosing Considerations

• Not interchangeable with other formulations of injectable triamcinolone acetonide
• Not suitable for use in small joints (e.g., hand)

Limitations of use

• Efficacy and safety of repeat administration of Zilretta have not been demonstrated

Pediatric:

Kenalog only; Zilretta safety and efficacy not established

Rheumatic or Arthritic Disorders

• Treatment of rheumatic or arthritic disorders
• Neonates: Not for use in neonates (contains benzyl alcohol)
• Children 6-12 years: 0.03-0.2 mg/kg IM every 1-7 days
• Children above 12 years: 60 mg IM every 6 weeks; may be supplemented by additional 20-100 mg IM as needed
• Children 12 years, intralesional injection (10 mg/mL suspension): 1 mg per injection site 1 or more times weekly; not to exceed 30 mg/day

Inflammatory and Allergic Systemic Conditions

• Initial dose of triamcinolone may vary depending on specific disease entity being treated
• 0.11-1.6 mg/kg/day IM divided every 3-4 hours

• Triamcinolone is administered as an injection in a clinical setting and acute overdose is unlikely.
• For chronic overdose because of severe disease requiring continuous steroid therapy, the dosage of the corticosteroid may be reduced only temporarily, or alternate day treatment may be introduced.
• Overdose treatment is symptomatic and supportive therapy.

Inform your doctor of all medications you are currently taking, who can advise you on any possible drug interactions. Never begin taking, suddenly discontinue, or change the dosage of any medication without your doctor’s recommendation.

• Severe interactions of triamcinolone include:
  • mifepristone
• Triamcinolone has serious interactions with at least 72 different drugs.
• Triamcinolone has moderate interactions with at least 229 different drugs.
• Triamcinolone has mild interactions with at least 121 different drugs.

The drug interactions listed above are not all of the possible interactions or adverse effects. For more information on drug interactions, visit the RxList Drug Interaction Checker.

It is important to always tell your doctor, pharmacist, or health care provider of all prescription and over-the-counter medications you use, as well as the dosage for each, and keep a list of the information. Check with your doctor or health care provider if you have any questions about the medication.

• There are no adequate and well-controlled studies of triamcinolone use in pregnant women, however, animal studies show it may cause fetal harm. Use triamcinolone during pregnancy only if maternal benefits outweigh potential fetal risks.
• Triamcinolone is present in breast milk and may suppress growth, interfere with natural (endogenous) corticosteroid production, or cause other untoward effects in the breastfed infant. Use with caution in nursing mothers.

• Do not take live or live, attenuated vaccines while receiving triamcinolone treatment.
• Corticosteroids can increase susceptibility to infections. Take precautions to avoid exposure to infections.
• Report to your physician if you develop infections or severe allergic reactions.
• Corticosteroids may cause mood and behavioral disturbances, notify your physician if you notice any unexplained mood or behavioral changes.