Triamcinolone (Systemic)

Dosage Forms

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

Kit, Injection, as acetonide:

Arze-Ject-A: 40 mg/mL (3 x 1 mL) [DSC] [contains benzyl alcohol, polysorbate 80]

P-Care K40: 40 mg/mL (1 x 1 mL) [contains benzyl alcohol, polysorbate 80]

P-Care K80: 40 mg/mL (2 x 1 mL) [contains benzyl alcohol, polysorbate 80]

Pod-Care 100K: 40 mg/mL (1 x 1 mL) [contains benzyl alcohol, polysorbate 80]

Pro-C-Dure 5: 40 mg/mL (2 x 1 mL) [contains benzyl alcohol, polysorbate 80]

Pro-C-Dure 6: 40 mg/mL (3 x 1 mL) [contains benzyl alcohol, polysorbate 80]

ReadySharp Triamcinolone: 40 mg/mL (1 x 1 mL) [DSC] [contains benzyl alcohol, polysorbate 80]

Suspension, Injection, as acetonide:

Kenalog: 10 mg/mL (5 mL); 40 mg/mL (1 mL, 5 mL, 10 mL) [contains benzyl alcohol, polysorbate 80]

Kenalog-80: 80 mg/mL (1 mL, 5 mL) [contains benzyl alcohol, polysorbate 80]

Generic: 40 mg/mL (1 mL, 5 mL, 10 mL)

Suspension Reconstituted ER, Intra-articular, as acetonide:

Zilretta: 32 mg (1 ea) [contains polysorbate 80]

Pharmacology

Mechanism of Action

A long acting corticosteroid with minimal sodium-retaining potential. Decreases inflammation by suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability; suppresses the immune system by reducing activity and volume of the lymphatic system; suppresses adrenal function at high doses

Pharmacokinetics/Pharmacodynamics

Distribution

V_d: IV (acetonide): 99.5 L

Metabolism

Hepatic (Asare 2007)

Excretion

Urine (75% primarily); bile and feces (25%) (Asare 2007)

Onset of Action

Adrenal suppression: IM (acetonide): 24 to 48 hours; Intra-articular: >24 hours

Duration of Action

Adrenal suppression: IM (acetonide): 30 to 40 days; Intra-articular: 28 to 42 days

Half-Life Elimination

Plasma: 300 minutes (Asare 2007)

Use: Labeled Indications

Intra-articular or soft tissue administration (triamcinolone hexacetonide [Canadian product]): Symptomatic treatment of subacute and chronic inflammatory joint diseases including: synovitis, tendinitis, bursitis, epicondylitis, rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), osteoarthritis, or post-traumatic arthritis.

Intralesional administration (triamcinolone acetonide [Kenalog-10 only]): Alopecia areata; discoid lupus erythematosus; keloids; localized hypertrophic, infiltrated, inflammatory lesions of granuloma annulare, lichen planus, lichen simplex chronicus (neurodermatitis), and psoriatic plaques; necrobiosis lipoidica diabeticorum; cystic tumors of an aponeurosis or tendon (ganglia).

Intramuscular administration (triamcinolone acetonide [Kenalog-40] only):

Allergic states: Control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment in asthma, drug hypersensitivity reactions, perennial or seasonal allergic rhinitis, serum sickness, or transfusion reactions.

Dermatologic diseases: Atopic dermatitis, bullous dermatitis herpetiformis, contact dermatitis, exfoliative erythroderma, mycosis fungoides, pemphigus, or severe erythema multiforme (Stevens-Johnson syndrome).

Endocrine disorders: Primary or secondary adrenocortical insufficiency (hydrocortisone or cortisone is the drug of choice), congenital adrenal hyperplasia, hypercalcemia associated with cancer, or nonsuppurative thyroiditis.

GI diseases: To tide the patient over a critical period of disease in Crohn disease or ulcerative colitis.

Hematologic disorders: Acquired (autoimmune) hemolytic anemia, Diamond-Blackfan anemia, pure red cell aplasia, select cases of secondary thrombocytopenia.

Neoplastic diseases: Palliative management of leukemias and lymphomas.

Nervous system: Acute exacerbations of multiple sclerosis; cerebral edema associated with primary or metastatic brain tumor or craniotomy. Note: Treatment guidelines recommend the use of high dose IV or oral methylprednisolone for acute exacerbations of multiple sclerosis (AAN [Scott 2011]; NICE 2014).

Ophthalmic diseases: Sympathetic ophthalmia, temporal arteritis, uveitis, and ocular inflammatory conditions unresponsive to topical corticosteroids.

Renal diseases: To induce diuresis or remission of proteinuria in idiopathic nephrotic syndrome or that is caused by lupus erythematosus.

Respiratory diseases: Berylliosis, fulminating or disseminated pulmonary tuberculosis when used concurrently with appropriate antituberculous chemotherapy, idiopathic eosinophilic pneumonias, symptomatic sarcoidosis.

Rheumatic disorders: As adjunctive therapy for short-term administration in acute gout flares; acute rheumatic carditis; ankylosing spondylitis; psoriatic arthritis; RA, including juvenile RA; treatment of dermatomyositis, polymyositis, and systemic lupus erythematosus.

Miscellaneous: Trichinosis with neurologic or myocardial involvement; tuberculous meningitis with subarachnoid block or impending block when used with appropriate antituberculous chemotherapy.

Contraindications

Triamcinolone acetonide: Hypersensitivity to triamcinolone or any component of the formulation; immune thrombocytopenia (formerly known as idiopathic thrombocytopenic purpura) (IM administration only)

Canadian labeling: Additional contraindications (not in US labeling): Systemic infections; injection into infected areas

Triamcinolone hexacetonide [Canadian product]: Hypersensitivity to triamcinolone or any component of the formulation; acute psychoses; active tuberculosis; herpes simplex keratitis; systemic mycoses; parasitosis (strongyloides infections); children <3 years of age (due to benzyl alcohol); epidural or intrathecal administration

Documentation of allergenic cross-reactivity for corticosteroids is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.

Dosage and Administration

Dosing: Adult

Note: Adjust dose depending upon condition being treated and response of patient. The lowest possible dose should be used to control the condition; when dose reduction is possible, the dose should be reduced gradually.

Dermatoses (steroid-responsive): Acetonide (Kenalog-10): 1 mg Intralesional: Initial dose varies depending on the specific disease and lesion being treated; may be repeated at weekly or less frequent intervals; multiple sites may be injected if they are 1 cm or more apart

Gout, acute flares (alternative agent): Note: Do not use if there is suspicion for infectious involvement.

Patients whose gout flare is limited to 1 to 2 joints and/or who are unable to take oral medications: Intra-articular: Acetonide (Kenalog-10): Larger joint (eg, knee): 40 mg; Medium joint (eg, wrist, ankle, elbow): 30 mg; Small joint: 10 mg (Becker 2018)

Patients with polyarticular involvement unable to take oral medications and who are not candidates for intra-articular injection: IM: Acetonide (Kenalog-40): Initial: 40 to 60 mg as a single dose; may repeat once or twice at ≥48-hour intervals if benefit fades or there is no flare resolution (Alloway 1993; Becker 2018; Siegal 1994)

Inflammatory/allergic conditions/other steroid-responsive systemic conditions: Acetonide (Kenalog-40): IM: Initial: 60 mg; adjust dose to a range of 40 to 80 mg. For patients with hay fever or pollen asthma who are not responding to pollen administration and other conventional therapy, a single injection of 40 mg to 100 mg per season may be given.

Multiple sclerosis (acute exacerbation):

Note: Treatment guidelines recommend the use of high dose IV or oral methylprednisolone for acute exacerbations of multiple sclerosis (AAN [Scott 2011]; NICE 2014).

Acetonide (Kenalog-40): IM: 160 mg daily for 1 week, followed by 64 mg every other day for 1 month.

Rheumatic conditions (excluding acute gout flares):

Intra-articular (or similar injection as designated):

Acetonide: Intra-articular, intrabursal, tendon sheaths: Initial: Smaller joints: 2.5 to 5 mg, larger joints: 5 to 15 mg; may require up to 10 mg for small joints and up to 40 mg for large joints; maximum dose/treatment (several joints at one time): 80 mg

Zilretta only: Intra-articular: Single dose: 32 mg. Note: For osteoarthritis (OA) pain of the knee only (use for OA pain of shoulder and hip have not been evaluated); use is not suitable for small joints (eg, hand). Safety and efficacy of repeat administration has not been studied.

Hexacetonide [Canadian product]: Intra-articular: Average dose: 2 to 20 mg; smaller joints (interphalangeal, metacarpophalangeal): 2 to 6 mg; large joints (knee, hip, shoulder): 10 to 20 mg. Frequency of injection into a single joint is every 3 to 4 weeks as necessary; to avoid possible joint destruction use as infrequently as possible.

IM: Acetonide (Kenalog-40): Initial: 60 mg; range: 2.5 to 100 mg/day

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Adjust dose depending upon condition being treated and response of patient. The lowest possible dose should be used to control the condition; when dose reduction is possible, the dose should be reduced gradually. Note: Aristospan Intra-Articular and Aristospan Intralesional have been discontinued in the US for more than 1 year.

General dosing, treatment of inflammatory and allergic conditions: Children and Adolescents:

Manufacturer's labeling: Acetonide (Kenolog-40): IM: Initial: 0.11 to 1.6 mg/kg/day (or 3.2 to 48 mg/m²/day) in 3 to 4 divided doses

Alternate dosing: Limited data available: Acetonide: Children 6 to 12 years: IM: 0.03 to 0.2 mg/kg/dose every 1 to 7 days (Kliegman, 2011)

Juvenile idiopathic arthritis (JIA), other rheumatic conditions:

Manufacturer's labeling: Children and Adolescents:

Acetonide (Kenalog-10 or -40): Intra-articular: Initial: Smaller joints: 2.5 to 5 mg, larger joints: 5 to 15 mg; maximum dose/treatment (several joints at one time): 20 to 80 mg

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

Alternate dosing: Limited data available: Children and Adolescents: Hexacetonide: Intra-articular: Large joints (typically knees, ankles): 1 to 1.5 mg/kg/dose; maximum dose: 40 mg; doses greater than 1.5 mg/kg have not been associated with additional clinical benefit; similar dosing for the acetonide salt can be used; however, data shows that the response is greater and lasts longer with hexacetonide (Bloom, 2011; Hashkes, 2005; Zulian, 2003; Zulian 2004)

Infantile hemangioma, severe: Limited data available: Infants and Children ≤49 months: Intralesional: Dosage dependent upon size of lesion: Commonly reported: 1 to 2 mg/kg/dose of the acetonide suspension (either 10 mg/mL or 40 mg/mL) administered in divided doses along the lesion perimeter ~monthly (4 to 5 weeks most frequently reported interval); a maximum dose up to 30 mg/dose has been used; others have reported: 1 to 30 mg of the 10 mg/mL acetonide injection divided into multiple injections along the lesion; has also been used in combination with betamethasone intralesional injections (Chen, 2000; Maguiness, 2012; Pandey, 2009; Praseyono, 2011). From the largest reported experience (n=1514, age range: 1 to 49 months), triamcinolone (1 to 2 mg/kg once every month) alone or in combination with oral corticosteroid (if no response after 6 injections of monotherapy) showed lesion size decrease of 50% or more in 90.3% of infants (age <1 year) and 80% in those >1 year (Pandey, 2009). Another trial (n=155, age range at first injection: 2 to 12 months) which used 1 to 30 mg of a 10 mg/mL concentration administered approximately once monthly (mean interval: 5 weeks) for 3 to 6 months showed lesion size decreased by at least 50% in 85% of the patients (Chen, 2000)

Dermatoses (steroid-responsive, including contact/atopic dermatitis):

Acetonide (Kenalog-10): Intradermal: Adolescents: Up to 1 mg per injection site and may be repeated 1 or more times weekly; multiple sites may be injected if they are 1 cm or more apart, not to exceed 30 mg

Hexacetonide (Aristospan 5 mg/mL): Intralesional, sublesional: Adolescents: Up to 0.5 mg/square inch of affected skin; initial range: 2 to 48 mg; frequency of dose is determined by clinical response

Reconstitution

Hexacetonide injectable suspension [Canadian product]: Avoid diluents containing parabens, phenol, or other preservatives (may cause flocculation). Solutions for intra-articular use may be diluted with lidocaine 1% or 2% (or similar local anesthetic).

Administration

Shake well before use to ensure suspension is uniform. Inspect visually to ensure no clumping; administer immediately after withdrawal so settling does not occur in the syringe. Do not administer any product IV or via the epidural or intrathecal route.

Acetonide:

Kenalog-10 injection: For intra-articular or intralesional administration only. When administered intralesionally, inject directly into the lesion (ie, intradermally or subcutaneously). One mL syringes with a 23- to 25-gauge needle are preferable for intralesional injections.

Kenalog-40 injection: For intra-articular, soft tissue or IM administration. When administered IM, inject deep into the gluteal muscle using a minimum needle length of 1¹/₂ inches. Obese patients may require a longer needle. Alternate sites for subsequent injections. Avoid IM injections into deltoid area.

Zilretta injection: For intra-articular administration only; do not administer IV, IM, SubQ, intrathecally, intraocularly, intradermally, or via epidural. Prepare suspension only using the diluent supplied in the kit (refer to manufacturer labeling for preparation instructions and administration techniques). Promptly inject after preparation. If needed, may store suspension in the vial ≤4 hours at ambient conditions; gently swirl vial to resuspend any settled microspheres prior to preparing syringe for injection. Aspiration of synovial fluid may be performed based on clinical judgment prior to administration.

Hexacetonide [Canadian product]: For intra-articular and soft tissue administration only; use a 25- or 26-gauge needle.

Dietary Considerations

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

Storage

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

Zilretta only: Store kit at 2°C to 8°C (36°F to 46°F). Do not freeze. If refrigeration is unavailable, may store unopened kit at ≤77°F (25°C) for ≤ 6 weeks. Do not store >77°F (25°C). May store reconstituted suspension in the vial ≤4 hours at ambient conditions.

Hexacetonide injectable suspension [Canadian product]: Store at 15°C to 30°C (59°F to 86°F).

Drug Interactions

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

Aldesleukin: Corticosteroids may diminish the antineoplastic effect of Aldesleukin. Avoid combination

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

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

Androgens: Corticosteroids (Systemic) may enhance the fluid-retaining effect of Androgens. Monitor therapy

Antidiabetic Agents: Hyperglycemia-Associated Agents may diminish the therapeutic effect of Antidiabetic Agents. Monitor therapy

Antihepaciviral Combination Products: May increase the serum concentration of Triamcinolone (Systemic). Monitor therapy

Aprepitant: May increase the serum concentration of Corticosteroids (Systemic). Management: No dose adjustment is needed for single 40 mg aprepitant doses. For other regimens, reduce oral dexamethasone or methylprednisolone doses by 50%, and IV methylprednisolone doses by 25%. Antiemetic regimens containing dexamethasone reflect this adjustment. Consider therapy modification

Axicabtagene Ciloleucel: Corticosteroids (Systemic) may diminish the therapeutic effect of Axicabtagene Ciloleucel. Management: Avoid use of corticosteroids as premedication before axicabtagene ciloleucel. Corticosteroids may, however, be required for treatment of cytokine release syndrome or neurologic toxicity. Consider therapy modification

Baricitinib: Immunosuppressants may enhance the immunosuppressive effect of Baricitinib. Management: Use of baricitinib in combination with potent immunosuppressants such as azathioprine or cyclosporine is not recommended. Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted. Consider therapy modification

BCG (Intravesical): Immunosuppressants may diminish the therapeutic effect of BCG (Intravesical). Avoid combination

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

Cladribine: May enhance the immunosuppressive effect of Immunosuppressants. Avoid combination

Coccidioides immitis Skin Test: Immunosuppressants may diminish the diagnostic effect of Coccidioides immitis Skin Test. Monitor therapy

Corticorelin: Corticosteroids may diminish the therapeutic effect of Corticorelin. Specifically, the plasma ACTH response to corticorelin may be blunted by recent or current corticosteroid therapy. Monitor therapy

Cosyntropin: Corticosteroids (Orally Inhaled) may diminish the diagnostic effect of Cosyntropin. Monitor therapy

Cosyntropin: Corticosteroids (Systemic) may diminish the diagnostic effect of Cosyntropin. Monitor therapy

CYP3A4 Inducers (Strong): May decrease the serum concentration of Corticosteroids (Systemic). Monitor therapy

CYP3A4 Inhibitors (Strong): May increase the serum concentration of Corticosteroids (Systemic). Monitor therapy

Deferasirox: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased. Monitor therapy

Deferasirox: Corticosteroids may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased. Monitor therapy

Denosumab: May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased. Monitor therapy

Desirudin: Corticosteroids (Systemic) may enhance the anticoagulant effect of Desirudin. More specifically, corticosteroids may increase hemorrhagic risk during desirudin treatment. Management: Discontinue treatment with systemic corticosteroids prior to desirudin initiation. If concomitant use cannot be avoided, monitor patients receiving these combinations closely for clinical and laboratory evidence of excessive anticoagulation. Consider therapy modification

Desmopressin: Corticosteroids (Systemic) may enhance the hyponatremic effect of Desmopressin. Avoid combination

Desmopressin: Corticosteroids (Orally Inhaled) may enhance the hyponatremic effect of Desmopressin. Avoid combination

DilTIAZem: May increase the serum concentration of Corticosteroids (Systemic). Monitor therapy

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

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

Fexinidazole [INT]: Corticosteroids (Systemic) may enhance the arrhythmogenic effect of Fexinidazole [INT]. Avoid combination

Fingolimod: Immunosuppressants may enhance the immunosuppressive effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and other immunosuppressants when possible. If combined, monitor patients closely for additive immunosuppressant effects (eg, infections). Consider therapy modification

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

Hyaluronidase: Corticosteroids may diminish the therapeutic effect of Hyaluronidase. Management: Patients receiving corticosteroids (particularly at larger doses) may not experience the desired clinical response to standard doses of hyaluronidase. Larger doses of hyaluronidase may be required. Consider therapy modification

Indacaterol: May enhance the hypokalemic effect of Corticosteroids (Systemic). Monitor therapy

Indium 111 Capromab Pendetide: Corticosteroids (Systemic) may diminish the diagnostic effect of Indium 111 Capromab Pendetide. Avoid combination

Isoniazid: Corticosteroids (Systemic) may decrease the serum concentration of Isoniazid. Monitor therapy

Leflunomide: Immunosuppressants may enhance the adverse/toxic effect of Leflunomide. Specifically, the risk for hematologic toxicity such as pancytopenia, agranulocytosis, and/or thrombocytopenia may be increased. Management: Consider not using a leflunomide loading dose in patients receiving other immunosuppressants. Patients receiving both leflunomide and another immunosuppressant should be monitored for bone marrow suppression at least monthly. Consider therapy modification

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

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

Loxapine: Agents to Treat Airway Disease may enhance the adverse/toxic effect of Loxapine. More specifically, the use of Agents to Treat Airway Disease is likely a marker of patients who are likely at a greater risk for experiencing significant bronchospasm from use of inhaled loxapine. Management: This is specific to the Adasuve brand of loxapine, which is an inhaled formulation. This does not apply to non-inhaled formulations of loxapine. Avoid combination

Macimorelin: Corticosteroids (Systemic) may diminish the diagnostic effect of Macimorelin. Avoid combination

Mifamurtide: Corticosteroids (Systemic) may diminish the therapeutic effect of Mifamurtide. Avoid combination

MiFEPRIStone: May diminish the therapeutic effect of Corticosteroids (Systemic). MiFEPRIStone may increase the serum concentration of Corticosteroids (Systemic). Management: Avoid mifepristone in patients who require long-term corticosteroid treatment of serious illnesses or conditions (e.g., for immunosuppression following transplantation). Corticosteroid effects may be reduced by mifepristone treatment. Avoid combination

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

Natalizumab: Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased. Avoid combination

Neuromuscular-Blocking Agents (Nondepolarizing): May enhance the adverse neuromuscular effect of Corticosteroids (Systemic). Increased muscle weakness, possibly progressing to polyneuropathies and myopathies, may occur. Consider therapy modification

Nicorandil: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nicorandil. Gastrointestinal perforation has been reported in association with this combination. Monitor therapy

Nivolumab: Immunosuppressants may diminish the therapeutic effect of Nivolumab. Consider therapy modification

Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective): Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective). Monitor therapy

Nonsteroidal Anti-Inflammatory Agents (Nonselective): Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents (Nonselective). Monitor therapy

Ocrelizumab: May enhance the immunosuppressive effect of Immunosuppressants. Monitor therapy

Pidotimod: Immunosuppressants may diminish the therapeutic effect of Pidotimod. Monitor therapy

Pimecrolimus: May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination

Quinolones: Corticosteroids (Systemic) may enhance the adverse/toxic effect of Quinolones. Specifically, the risk of tendonitis and tendon rupture may be increased. Monitor therapy

Ritodrine: Corticosteroids may enhance the adverse/toxic effect of Ritodrine. Monitor therapy

Ritonavir: May enhance the adverse/toxic effect of Triamcinolone (Systemic). Specifically, risks of developing iatrogenic Cushing syndrome and secondary adrenal insufficiency may be increased. Ritonavir may increase the serum concentration of Triamcinolone (Systemic). Monitor therapy

Roflumilast: May enhance the immunosuppressive effect of Immunosuppressants. Consider therapy modification

Salicylates: May enhance the adverse/toxic effect of Corticosteroids (Systemic). These specifically include gastrointestinal ulceration and bleeding. Corticosteroids (Systemic) may decrease the serum concentration of Salicylates. Withdrawal of corticosteroids may result in salicylate toxicity. Monitor therapy

Sargramostim: Corticosteroids (Systemic) may enhance the therapeutic effect of Sargramostim. Specifically, corticosteroids may enhance the myeloproliferative effects of sargramostim. Monitor therapy

Siponimod: Immunosuppressants may enhance the immunosuppressive effect of Siponimod. Monitor therapy

Sipuleucel-T: Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Management: Evaluate patients to see if it is medically appropriate to reduce or discontinue therapy with immunosuppressants prior to initiating sipuleucel-T therapy. Consider therapy modification

Somatropin: Corticosteroids (Systemic) may diminish the therapeutic effect of Somatropin. Monitor therapy

Tacrolimus (Systemic): Corticosteroids (Systemic) may decrease the serum concentration of Tacrolimus (Systemic). Conversely, when discontinuing corticosteroid therapy, tacrolimus concentrations may increase. Monitor therapy

Tacrolimus (Topical): May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination

Tertomotide: Immunosuppressants may diminish the therapeutic effect of Tertomotide. Monitor therapy

Thiazide and Thiazide-Like Diuretics: Corticosteroids (Systemic) may enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics. Monitor therapy

Thiazide and Thiazide-Like Diuretics: Corticosteroids (Orally Inhaled) may enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics. Monitor therapy

Tisagenlecleucel: Corticosteroids (Systemic) may diminish the therapeutic effect of Tisagenlecleucel. Management: Avoid use of corticosteroids as premedication or at any time during treatment with tisagenlecleucel, except in the case of life-threatening emergency (such as resistant cytokine release syndrome). Consider therapy modification

Tobacco (Smoked): May diminish the therapeutic effect of Corticosteroids (Orally Inhaled). Monitor therapy

Tofacitinib: Immunosuppressants may enhance the immunosuppressive effect of Tofacitinib. Management: Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted, and this warning seems particularly focused on more potent immunosuppressants. Consider therapy modification

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

Upadacitinib: Immunosuppressants may enhance the immunosuppressive effect of Upadacitinib. Avoid combination

Urea Cycle Disorder Agents: Corticosteroids (Systemic) may diminish the therapeutic effect of Urea Cycle Disorder Agents. More specifically, Corticosteroids (Systemic) may increase protein catabolism and plasma ammonia concentrations, thereby increasing the doses of Urea Cycle Disorder Agents needed to maintain these concentrations in the target range. Monitor therapy

Vaccines (Inactivated): Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation. Consider therapy modification

Vaccines (Live): Corticosteroids (Systemic) may enhance the adverse/toxic effect of Vaccines (Live). Corticosteroids (Systemic) may diminish the therapeutic effect of Vaccines (Live). Management: Doses equivalent to less than 2 mg/kg or 20 mg per day of prednisone administered for less than 2 weeks are not considered sufficiently immunosuppressive to create vaccine safety concerns. Higher doses and longer durations should be avoided. Consider therapy modification

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

Adverse Reactions

1% to 10%:

Hematologic & oncologic: Bruise (extended release: 2%)

Neuromuscular & skeletal: Joint swelling (extended release: 3%)

Respiratory: Cough (extended release: 2%), sinusitis (extended release: 2%)

Frequency not defined. Most reactions listed are based on reports for other agents in this same pharmacologic class and may not be specifically reported for systemic triamcinolone:

Cardiovascular: Bradycardia, cardiac arrhythmia, cardiac failure, cardiomegaly, cerebrovascular accident, circulatory shock, edema, embolism (fat), hypertension, hypertrophic cardiomyopathy (premature infants), myocardial rupture (following recent myocardial infarction), syncope, tachycardia, thromboembolism, thrombophlebitis, vasculitis

Central nervous system: Abnormal sensory symptoms, arachnoiditis, depression, emotional lability, euphoria, headache, idiopathic intracranial hypertension (upon discontinuation), increased intracranial pressure, insomnia, malaise, meningitis, mood changes, myasthenia, neuritis, neuropathy, paraplegia, paresthesia, personality changes, psychiatric disturbance, quadriplegia, seizure, spinal cord infarction, vertigo

Dermatologic: Acne vulgaris, allergic dermatitis, atrophic striae, diaphoresis, ecchymoses, epidermal thinning, erythema of skin, exfoliation of skin, hyperpigmentation, hypertrichosis, hypopigmentation, inadvertent suppression of skin test reaction, skin atrophy, skin rash, subcutaneous atrophy, thinning hair, urticaria, xeroderma

Endocrine & metabolic: Calcinosis, decreased glucose tolerance, decreased serum potassium, diabetes mellitus, drug-induced Cushing's syndrome, fluid retention, glycosuria, growth retardation, hirsutism, impaired glucose tolerance/prediabetes, insulin resistance, menstrual disease, moon face, negative nitrogen balance, redistribution of body fat, secondary adrenocortical insufficiency, sodium retention, weight gain

Gastrointestinal: Abdominal distention, change in bowel habits, gastrointestinal hemorrhage, gastrointestinal perforation, hiccups, increased appetite, nausea, pancreatitis, peptic ulcer, ulcerative esophagitis

Genitourinary: Bladder dysfunction, postmenopausal bleeding, spermatozoa disorder

Hematologic & oncologic: Nonthrombocytopenic purpura, petechia

Hepatic: Hepatomegaly, increased liver enzymes

Hypersensitivity: Anaphylaxis, angioedema

Infection: Increased susceptibility to infection, infection, sterile abscess

Local: Postinjection flare

Neuromuscular & skeletal: Amyotrophy, aseptic necrosis of femoral head, aseptic necrosis of humeral head, bone fracture, Charcot arthropathy, lupus erythematous-like rash, osteoporosis, rupture of tendon, steroid myopathy, vertebral compression fracture

Ophthalmic: Blindness (periocular; rare), cataract, cortical blindness, exophthalmos, glaucoma, increased intraocular pressure, papilledema

Renal: Increased urine calcium excretion

Respiratory: Pulmonary edema

Miscellaneous: Wound healing impairment

Warnings/Precautions

Concerns related to adverse effects:

• Adrenal suppression: May cause hypercortisolism or suppression of hypothalamic-pituitary-adrenal (HPA) axis, particularly in younger children or in patients receiving high doses for prolonged periods. HPA axis suppression may lead to adrenal crisis. Withdrawal and discontinuation of a corticosteroid should be done slowly and carefully. Particular care is required when patients are transferred from systemic corticosteroids to inhaled products due to possible adrenal insufficiency or withdrawal from steroids, including an increase in allergic symptoms. Adult patients receiving >20 mg per day of prednisone (or equivalent) may be most susceptible. Fatalities have occurred due to adrenal insufficiency in asthmatic patients during and after transfer from systemic corticosteroids to aerosol steroids; aerosol steroids do not provide the systemic steroid needed to treat patients having trauma, surgery, or infections.
• Anaphylactoid reactions: Rare cases of anaphylactoid reactions have been observed in patients receiving corticosteroids. Cases of serious anaphylaxis, including death, have been reported with triamcinolone acetonide.
• Dermal changes: Atrophy at the injection site has been reported. Avoid IM deltoid injection; subcutaneous atrophy may occur.
• Immunosuppression: Prolonged use of corticosteroids may also increase the incidence of secondary infection, cause activation of latent infections, mask acute infection (including fungal infections), prolong or exacerbate viral infections, or limit response to killed or inactivated vaccines. Exposure to chickenpox or measles should be avoided; corticosteroids should not be used to treat ocular herpes simplex, cerebral malaria, fungal infections, or viral hepatitis. Close observation is required in patients with latent tuberculosis and/or TB reactivity; restrict use in active TB (only fulminating or disseminated TB in conjunction with antituberculosis treatment). Amebiasis should be ruled out in any patient with recent travel to tropic climates or unexplained diarrhea prior to initiation of corticosteroids. Use with extreme caution in patients with Strongyloides infections; hyperinfection, dissemination, and fatalities have occurred.
• Kaposi sarcoma: Prolonged treatment with corticosteroids has been associated with the development of Kaposi sarcoma (case reports); if noted, discontinuation of therapy should be considered (Goedert 2002).
• Myopathy: Acute myopathy has been reported with high-dose corticosteroids, usually in patients with neuromuscular transmission disorders or when given concomitantly with neuromuscular blocking agents; may involve ocular and/or respiratory muscles; monitor creatine kinase; recovery may be delayed.
• Psychiatric disturbances: Corticosteroid use may cause psychiatric disturbances, including euphoria, insomnia, mood swings, and personality changes to severe depression and frank psychotic manifestations. Preexisting psychiatric conditions may be exacerbated by corticosteroid use.
• Septic arthritis: May occur as a complication to intra-articular or soft tissue administration; institute appropriate antimicrobial therapy as required.

Disease-related concerns:

• Cardiovascular disease: Use with caution in patients with HF and/or hypertension; use has been associated with fluid retention, electrolyte disturbances, and hypertension. Use with caution following acute MI; corticosteroids have been associated with myocardial rupture.
• Diabetes: Use corticosteroids with caution in patients with diabetes mellitus; may alter glucose production/regulation leading to hyperglycemia.
• Gastrointestinal disease: Use with caution or avoid use in patients with GI diseases (diverticulosis, diverticulitis, fresh intestinal anastomoses, active or latent peptic ulcer, ulcerative colitis, abscess or other pyogenic infection) due to perforation risk.
• Head injury: Increased mortality was observed in patients receiving high-dose IV methylprednisolone; high-dose corticosteroids should not be used for the management of head injury.
• Hepatic impairment: Use with caution in patients with hepatic impairment, including cirrhosis; long-term use has been associated with fluid retention.
• Myasthenia gravis: Use with caution in patients with myasthenia gravis; exacerbation of symptoms has occurred, especially during initial treatment with corticosteroids.
• Ocular disease: Use with caution in patients with cataracts and/or glaucoma; increased intraocular pressure, open-angle glaucoma, and cataracts have occurred with prolonged use. Use with caution in patients with a history of ocular herpes simplex; corneal perforation has occurred; do not use in active ocular herpes simplex. Not recommended for the treatment of optic neuritis; may increase frequency of new episodes. Consider routine eye exams in chronic users.
• Osteoporosis: Use with caution in patients with osteoporosis; high doses and/or long-term use of corticosteroids have been associated with increased bone loss and osteoporotic fractures.
• Renal impairment: Use with caution in patients with renal impairment; fluid retention may occur.
• Seizure disorders: Use corticosteroids with caution in patients with a history of seizure disorder; seizures have been reported with adrenal crisis.
• Thyroid disease: Changes in thyroid status may necessitate dosage adjustments; metabolic clearance of corticosteroids increases in hyperthyroid patients and decreases in hypothyroid ones.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• Elderly: Use with caution in the elderly with the smallest possible effective dose for the shortest duration.
• Pediatric: May affect growth velocity; growth should be routinely monitored in pediatric patients.

Dosage form specific issues:

• Benzyl alcohol and derivatives: Some dosage forms may contain benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997], CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol with caution in neonates. See manufacturer's labeling.
• Polysorbate 80: Some dosage forms may contain polysorbate 80 (also known as Tweens). Hypersensitivity reactions, usually a delayed reaction, have been reported following exposure to pharmaceutical products containing polysorbate 80 in certain individuals (Isaksson 2002, Lucente 2000, Shelley 1995). Thrombocytopenia, ascites, pulmonary deterioration, and renal and hepatic failure have been reported in premature neonates after receiving parenteral products containing polysorbate 80 (Alade 1986; CDC 1984). See manufacturer's labeling.

Other warnings/precautions:

• Appropriate administration: Administer products only via recommended route (depending on product used). Do not administer any triamcinolone product via the intrathecal route; serious adverse events, including fatalities, have been reported following intrathecal administration of corticosteroids.
• Discontinuation of therapy: Withdraw therapy with gradual tapering of dose.
• Epidural injection: Corticosteroids are not approved for epidural injection. Serious neurologic events (eg, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, stroke), some resulting in death, have been reported with epidural injection of corticosteroids, with and without use of fluoroscopy.
• Intra-articular injection: May result in damage to joint tissues. Avoid injection into an infected site; injection into a previously infected joint is not usually recommended. Injection into unstable joints is generally not recommended. Examine any joint fluid present to exclude a septic process.
• Stress: Patients may require higher doses when subject to stress (ie, trauma, surgery, severe infection).

Monitoring Parameters

Blood pressure, blood glucose, electrolytes; weight; intraocular pressure (use >6 weeks); bone mineral density; growth and development in children; HPA axis suppression

Pregnancy

Pregnancy Considerations

Adverse events have been observed with corticosteroids in animal reproduction studies.

Some studies have shown an association between first trimester systemic corticosteroid use and oral clefts or decreased birth weight; however, information is conflicting and may be influenced by maternal dose/indication for use (Lunghi 2010; Park-Wyllie 2000; Pradat 2003). Hypoadrenalism may occur in newborns following maternal use of corticosteroids in pregnancy; monitor.

When systemic corticosteroids are needed in pregnancy for rheumatic disorders, it is generally recommended to use the lowest effective dose for the shortest duration of time, avoiding high doses during the first trimester. Intra-articular dosing may be used (Götestam Skorpen 2016; Makol 2011; Østensen 2009).

For dermatologic disorders in pregnant females, systemic corticosteroids are generally not preferred for initial therapy; should be avoided during the first trimester; and used during the second or third trimester at the lowest effective dose (Bae 2012; Leachman 2006).

Patient Education

What is this drug used for?

• It is used to treat arthritis of the knee.
• It is used for many health problems like allergy signs, asthma, adrenal gland problems, blood problems, skin rashes, or swelling problems.
• This is not a list of all health problems that this drug may be used for. Talk with the doctor.

Frequently reported side effects of this drug

• Nausea
• Vomiting
• Trouble sleeping
• Agitation
• Hair thinning

Other side effects of this drug: Talk with your doctor right away if you have any of these signs of:

• Infection
• High blood sugar like confusion, fatigue, increased thirst, increased hunger, passing a lot of urine, flushing, fast breathing, or breath that smells like fruit
• Cushing syndrome like weight gain in upper back or abdomen; moon face; severe headache; or slow healing
• Adrenal gland problems like severe nausea, vomiting, severe dizziness, passing out, muscle weakness, severe fatigue, mood changes, lack of appetite, or weight loss
• Low potassium like muscle pain or weakness, muscle cramps, or an abnormal heartbeat
• Severe abdominal pain
• Loss of strength and energy
• Irritability
• Tremors
• Fast heartbeat
• Confusion
• Sweating a lot
• Severe headache
• Severe dizziness
• Passing out
• Shortness of breath
• Excessive weight gain
• Swelling of arms or legs
• Bruising
• Bleeding
• Vomiting blood
• Thrush
• Bone pain
• Joint pain
• Joint swelling
• Vision changes
• Mood changes
• Behavioral changes
• Depression
• Menstrual changes
• Seizures
• Burning or numbness feeling
• Injection site redness or swelling
• Skin changes like acne, stretch marks, slow healing, or hair growth
• Black, tarry, or bloody stools
• Signs of a significant reaction like wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.