Triamcinolone

Class: Adrenals
Note: This monograph also contains information on Triamcinolone Acetonide, Triamcinolone Hexacetonide
VA Class: RE101
CAS Number: 124-94-7
Brands: Aristocort, Aristospan, Azmacort, Kenalog

Introduction

Synthetic glucocorticoid; virtually no mineralocorticoid activity.^{c j}

Uses for Triamcinolone

Treatment of a wide variety of diseases and conditions principally for glucocorticoid effects as an anti-inflammatory and immunosuppressant agent and for its effects on blood and lymphatic systems in the palliative treatment of various diseases.^b

Usually inadequate alone for adrenocortical insufficiency because essentially devoid of mineralocorticoid activity.^{b c j}

Adrenocortical Insufficiency

Corticosteroids are administered in physiologic dosages to replace deficient endogenous hormones in patients with adrenocortical insufficiency.^b

Because production of both mineralocorticoids and glucocorticoids is deficient in adrenocortical insufficiency, hydrocortisone or cortisone (in conjunction with liberal salt intake) usually is the corticosteroid of choice for replacement therapy.^{b j}

If triamcinolone is used, must also administer a mineralocorticoid (fludrocortisone), particularly in infants.^{b j}

Adrenogenital Syndrome

Lifelong glucocorticoid treatment of congenital adrenogenital syndrome.^b

In salt-losing forms, cortisone or hydrocortisone is preferred in conjunction with liberal salt intake; a mineralocorticoid may be necessary in conjunction through at least 5–7 years of age.^b A glucocorticoid, usually alone, is continued for long-term therapy after early childhood.^{b j}

In hypertensive forms, a “short-acting” glucocorticoid with minimal mineralocorticoid activity (e.g., methylprednisolone, prednisone) is preferred;^b avoid long-acting glucocorticoids because of tendency toward overdosage and growth retardation.^b

Hypercalcemia

Treatment of hypercalcemia associated with malignancy.^{b j}

Usually ameliorates hypercalcemia associated with bone involvement in multiple myeloma.^b

Treatment of hypercalcemia associated with sarcoidosis†.^{b m}

Treatment of hypercalcemia associated with vitamin D intoxication†.^b

Not effective for hypercalcemia caused by hyperparathyroidism†.^b

Thyroiditis

Treatment of granulomatous (subacute, nonsuppurative) thyroiditis.^{b d j} Anti-inflammatory actions relieve fever, acute thyroid pain, and swelling.^b

Usually reserved for palliative therapy in severely ill patients unresponsive to salicylates and thyroid hormones.^b

May reduce orbital edema in endocrine exophthalmos (thyroid ophthalmopathy).^b

Rheumatic Disorders and Collagen Diseases

Short-term palliative treatment of acute episodes or exacerbations and systemic complications of rheumatic disorders (e.g., rheumatoid arthritis, juvenile rheumatoid arthritis, psoriatic arthritis, acute gouty arthritis, posttraumatic osteoarthritis, synovitis of osteoarthritis, epicondylitis, acute nonspecific tenosynovitis, ankylosing spondylitis, acute and subacute bursitis, Reiter syndrome†^m , rheumatic fever† [especially with carditis]^m ) and collagen diseases (e.g., acute rheumatic carditis, systemic lupus erythematosus, polyarteritis nodosa†^m , vasculitis†^m ) refractory to more conservative measures.^{b c d e g h j}

Relieves inflammation and suppresses symptoms but not disease progression.^b

Rarely indicated as maintenance therapy.^b

May be used as maintenance therapy (e.g., in rheumatoid arthritis, acute gouty arthritis, systemic lupus erythematosus, acute rheumatic carditis) as part of a total treatment program in selected patients when more conservative therapies have proven ineffective.^b However, glucocorticoid withdrawal is extremely difficult in these patients; relapse and recurrence usually occur with drug discontinuance.^b

Local injection can provide dramatic relief initially for articular manifestations of rheumatic disorders (e.g., rheumatoid arthritis) that involve only a few persistently inflamed joints or for inflammation of tendons or bursae;^b inflammation tends to recur and sometimes is more intense after drug cessation.^b

Local injection can prevent invalidism by facilitating movement of joints that might otherwise become immobile.^b

Controls acute manifestations of rheumatic carditis^{b m} more rapidly than salicylates and may be life-saving; cannot prevent valvular damage and is no better than salicylates for long-term treatment.^b

Adjunctively for severe systemic complications of Wegener's granulomatosis†, but cytotoxic therapy is the treatment of choice.^b

Primary treatment to control symptoms and prevent severe, often life-threatening complications in patients with polyarteritis nodosa†, relapsing polychondritis†, polymyalgia rheumatica†, or mixed connective tissue disease syndrome†.^b High dosage may be required for acute situations; after a response has been obtained, drug must often be continued for long periods at low dosage.^b

In osteoarthritis†, intra-articular injections may be beneficial but should be limited in number as joint damage may occur.^{b d e}

Dermatologic Diseases

Treatment of pemphigus and pemphigoid†^m , bullous dermatitis herpetiformis, severe erythema multiforme (Stevens-Johnson syndrome), exfoliative dermatitis, uncontrollable eczema†^m , cutaneous sarcoidosis†^m , mycosis fungoides, lichen planus, severe psoriasis, and severe seborrheic dermatitis.^{b d e h j}

Rarely indicated for psoriasis.^{b d j} If used, exacerbation may occur when the drug is withdrawn or dosage is decreased.^{b j}

Usually reserved for acute exacerbations unresponsive to conservative therapy.^b

Early initiation of systemic glucocorticoid therapy may be life-saving in pemphigus vulgaris and pemphigoid†, and high or massive doses may be required.^b

For control of severe or incapacitating allergic conditions (e.g., contact dermatitis, atopic dermatitis) intractable to adequate trials of conventional treatment.^{d j}

Chronic skin disorders seldom an indication for systemic glucocorticoids.^b

Intralesional or sublesional injections occasionally indicated for localized chronic skin disorders including keloids, psoriatic plaques, alopecia areata, discoid lupus erythematosus, necrobiosis lipoidica diabeticorum, granuloma annulare, or lichen simplex chronics (neurodermatitis)^e unresponsive to topical therapy.^{b e h}

Rarely indicated systemically for alopecia (areata, totalis, or universalis).^b May stimulate hair growth, but hair loss returns when the drug is discontinued.^b

Allergic Conditions

For control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment and control of acute manifestations, including serum sickness, drug hypersensitivity reactions, and severe seasonal or perennial rhinitis.^{b d j}

Systemic therapy usually reserved for acute conditions and severe exacerbations.^b

For acute conditions, usually used in high dosage and with other therapies (e.g., antihistamines, sympathomimetics).^b

Reserve prolonged treatment of chronic allergic conditions for disabling conditions unresponsive to more conservative therapy and when risks of long-term glucocorticoid therapy are justified.^b

Ocular Disorders

To suppress a variety of allergic and nonpyogenic ocular inflammations.^b

To reduce scarring in ocular injuries†.^b

For the treatment of severe acute and chronic allergic and inflammatory processes involving the eye and adnexa (e.g., allergic conjunctivitis, keratitis, allergic corneal marginal ulcers, herpes zoster ophthalmicus, iritis and iridocyclitis, chorioretinitis, diffuse posterior uveitis and choroiditis, anterior segment inflammation, optic neuritis, sympathetic ophthalmia).^{b d j}

Acute optic neuritis optimally treated with initial high-dose IV therapy (e.g., methylprednisolone) followed by chronic oral therapy. Can slow progression to clinically definite multiple sclerosis.

Less severe allergic and inflammatory allergic conditions of the eye are treated with topical (to the eye) corticosteroids.ⁱ

Systemically in stubborn cases of anterior segment eye disease and when deeper ocular structures are involved.^b

Asthma

Used by oral inhalation for the long-term prevention of bronchospasm in patients with asthma.^{102 104 105}

Used orally for severe bronchial asthma intractable to conventional treatment.^j

Used orally for treatment of moderate to severe acute exacerbations of asthma (oral prednisone usually preferred).^j Speeds resolution of airflow obstruction and reduces rate of relapse.^j

Because onset of effects is delayed, do not use alone for emergency treatment.

Early systemic glucocorticoid therapy particularly important for asthma exacerbations in infants and children.ⁱ

In hospital management of an acute asthma exacerbation, systemic adjunctive glucocorticoids if response to oral inhalation therapy is not immediate, if oral corticosteroids were used as self-medication prior to hospitalization, or if the episode is severe.^b

For severe persistent asthma once initial control is achieved, high dosages of inhaled corticosteroids are preferable to oral corticosteroids for maintenance because inhaled corticosteroids have fewer systemic effects.

Maintenance therapy with low doses of an orally inhaled corticosteroid is preferred treatment for adults and children with mild persistent asthma (i.e., patients with daytime symptoms of asthma more than twice weekly but less than once daily, and nocturnal symptoms of asthma more than twice per month).^{102 104}

A long-acting β₂-agonist (e.g., formoterol, salmeterol) added to low- to medium-dose inhaled corticosteroids is the preferred therapy in patients with moderate persistent asthma (i.e., patients with daily asthmatic symptoms); ^{102 104} alternatively, may increase (e.g., double) maintenance dosage of inhaled corticosteroid within medium-dosage range in such patients.^{102 104}

Orally as an adjunct to other therapy to speed resolution of all but the mildest exacerbations of asthma when response to a short-acting inhaled β₂-agonist is not prompt or sustained after 1 hour or in those who have a history of severe exacerbations.^c

Oral glucocorticoids with minimal mineralocorticoid activity and relatively short half-life (e.g., prednisone, prednisolone, methylprednisolone) are preferred.

Do not use oral inhalation for the treatment of nonasthmatic bronchitis or for relief of acute bronchospasm.¹⁰⁵

COPD

For severe exacerbations of COPD†, a short (e.g., 1–2 weeks) course of oral glucocorticoids can be added to existing therapy.

Effects in stable COPD are much less dramatic than in asthma, and role of glucocorticoids in the management of stable COPD is limited to very specific indications.

Inhaled corticosteroids are not appropriate in the treatment of acute exacerbations of COPD.

Sarcoidosis

Management of symptomatic sarcoidosis.^{b d j}

Systemic glucocorticoids are indicated for hypercalcemia; ocular, CNS, glandular, myocardial, or severe pulmonary involvement; or severe skin lesions unresponsive to intralesional injections of glucocorticoids.^b

Advanced Pulmonary and Extrapulmonary Tuberculosis

Systemically as adjunctive therapy with effective antimycobacterial agents (e.g., streptomycin, isoniazid) to suppress manifestations related to the host’s inflammatory response to the bacillus (Mycobacterium tuberculosis) and ameliorate complications in severe pulmonary or extrapulmonary tuberculosis.

Adjunctive glucocorticoid therapy may enhance short-term resolution of disease manifestations (e.g., clinical and radiographic abnormalities) in advanced pulmonary tuberculosis and also may reduce mortality associated with certain forms of extrapulmonary disease (e.g., meningitis, pericarditis).

Systemic adjunctive glucocorticoids may reduce sequelae (e.g., intellectual impairment) and/or improve survival in moderate to severe tuberculous meningitis.

Systemic adjunctive glucocorticoid therapy rapidly reduces the size of pericardial effusions and the need for drainage procedures and decreases mortality (probably through control of hemodynamically threatening effusion) in acute tuberculous pericarditis.

Hastens the resolution of pain, dyspnea, and fever associated with tuberculous pleurisy.^b

Loeffler’s Syndrome

Symptomatic relief of acute manifestations of symptomatic Loeffler’s syndrome not manageable by other means.^j

Berylliosis

Symptomatic relief of acute manifestations of berylliosis.^j

Aspiration Pneumonitis

Symptomatic relief of acute manifestations of aspiration pneumonitis.^j

Hematologic Disorders

Management of acquired (autoimmune) hemolytic anemia, idiopathic thrombocytopenic purpura (ITP), secondary thrombocytopenia, erythroblastopenia, or congenital (erythroid) hypoplastic anemia.^{d j}

High or even massive glucocorticoid dosages decrease bleeding tendencies and normalize blood counts; does not affect the course or duration of hematologic disorders.^b

Glucocorticoids, immune globulin IV (IGIV), or splenectomy are first-line therapies for moderate to severe ITP, depending on the extent of bleeding involved.

Glucocorticoids may not affect or prevent renal complications in Henoch-Schoenlein purpura.^b

Insufficient evidence of effectiveness of glucocorticoids in aplastic anemia in children, but widely used.^b

Pericarditis

To reduce the pain, fever, and inflammation of pericarditis†, including that associated with MI.^{b m}

Glucocorticoids can provide effective symptomatic relief, but aspirin considered the treatment of choice for post-MI pericarditis because of greater evidence establishing benefit.

Important to distinguish between pain caused by pericarditis and that caused by ischemia since management will differ.

Glucocorticoids may cause thinning of developing scar and myocardial rupture.^g Consider possibility that cardiac rupture may account for recurrent pain since use of glucocorticoids may be a risk factor in its development. (See Cardiovascular Effects under Cautions.)

Management of tuberculous pericarditis. (See Advanced Pulmonary and Extrapulmonary Tuberculosis under Uses.)

GI Diseases

Short-term palliative therapy for acute exacerbations and systemic complications of ulcerative colitis, regional enteritis, and Crohn's disease†^m .^{b d j}

Do not use if a probability of impending peforation, abscess, or other pyogenic infection.^b

Rarely indicated for maintenance therapy in chronic GI diseases (e.g., ulcerative colitis) since does not prevent relapses and may produce severe adverse reactions with long-term administration.^b

Occasionally, low dosages, in conjunction with other supportive therapy, may be useful for disease unresponsive to the usual therapy indicated for chronic conditions.^b

Neoplastic Diseases

Alone or as a component of various chemotherapeutic regimens in the palliative treatment of neoplastic diseases of the lymphatic system (e.g., leukemias and lymphomas in adults and acute leukemias in children).^{d j}

Treatment of breast cancer†^m ; glucocorticoids alone not as effective as other agents (e.g., cytotoxic agents, hormones, antiestrogens) and should be reserved for unresponsive disease.^b

Glucocorticoids alone or as a component of various combination chemotherapeutic regimens for palliative treatment of advanced, symptomatic (i.e., painful) hormone-refractory prostate cancer†.^m

Low Back Pain

Has been used epidurally (alone or combined with a local anesthetic and/or an opiate analgesic) for symptomatic relief of low back pain†; although use remains controversial and convincing evidence of efficacy is lacking, most experts consider such therapy an option for short-term relief of acute, subacute, or chronic radicular pain in patients with low back pain and radiculopathy associated with disk disease or herniation or spinal stenosis when more conservative therapies (e.g., rest, analgesics, physical therapy) fail and as a means of potentially avoiding surgery.

Limited evidence suggests that therapeutic facet joint† and intradiscal glucocorticoid injections† are minimally effective or ineffective in the treatment of low back pain, although facet joint injections may be useful in some patients with facet arthropathy. Inclusion of a glucocorticoid in trigger point injections does not appear to be beneficial.

Sacroiliac joint injections performed using fluoroscopic guidance may provide temporary pain relief in some patients when the principal source of spinal pain is the sacroiliac joint.

Oral glucocorticoids† have been used; however, they do not appear to be effective and evidence supporting such use is lacking.

Multiple Sclerosis

Glucocorticoids are drugs of choice for the management of acute relapses of multiple sclerosis.^j

Anti-inflammatory and immunomodulating effects accelerate neurologic recovery by restoring the blood-brain barrier, reducing edema, and possibly improving axonal conduction.

Shortens the duration of relapse and accelerates recovery; remains to be established whether the overall degree of recovery improves or the long-term course is altered.

Myasthenia Gravis

Management of myasthenia gravis†, usually when there is an inadequate response to anticholinesterase therapy.^m

Organ Transplants

In massive dosage, used concomitantly with other immunosuppressive drugs to prevent rejection of transplanted organs†.^{b m}

Incidence of secondary infections is high with immunosuppressive drugs; limit to clinicians experienced in their use.^b

Trichinosis

Treatment of trichinosis with neurologic or myocardial involvement.^j

Nephrotic Syndrome and Lupus Nephritis

Treatment of idiopathic nephrotic syndrome without uremia.^d

Can induce diuresis and remission of proteinuria in nephrotic syndrome^d secondary to primary renal disease, especially when there is minimal renal histologic change.^b

Treatment of lupus nephritis.^d

Carpal Tunnel Syndrome

Local injection of glucocorticoids into the tissue near the carpal tunnel has been used in a limited number of patients to relieve symptoms (e.g., pain, edema, sensory deficit) of carpal tunnel syndrome†.

Triamcinolone Dosage and Administration

General

• 
  

  Route of administration and dosage depend on the condition being treated and patient response.^c

  
  


• 
  

  Individualize dosage carefully according to the diagnosis, severity, prognosis and probable duration of the disease, and patient response and tolerance.^{b d e j}

  
  


• 
  

  Long-term therapy should not be initiated without due consideration of its risks.^b If necessary, administer in the smallest dosage possible.^{b j} Continual monitoring is recommended for signs that indicate dosage adjustment is necessary (e.g., remission or exacerbations of the disease and stress [surgery, infection, trauma]).^{b j}

  
  

Alternate-Day Therapy

• 
  

  Alternate-day therapy in which a single dose is administered every other morning is the dosage regimen of choice for long-term oral glucocorticoid treatment of most conditions.^b This regimen provides relief of symptoms while minimizing adrenal suppression, protein catabolism, and other adverse effects.^b

  
  


• 
  

  Although triamcinolone's HPA-axis suppression persists for 2.25 days, the manufacturer recommends that an alternate-day dosage regimen may be considered for some patients receiving long-term oral therapy.^j However, most authorities consider only a “short-acting” glucocorticoid that suppresses the HPA axis <1.5 days after a single oral dose (e.g., prednisone, prednisolone, methylprednisolone) to be suitable.^{b c}

  
  


• 
  

  Some conditions (e.g., rheumatoid arthritis, ulcerative colitis) require daily glucocorticoid therapy because symptoms of the underlying disease cannot be controlled by alternate-day therapy.^b

  
  

Discontinuance of Therapy

• 
  

  A steroid withdrawal syndrome consisting of lethargy, fever, myalgia can develop following abrupt discontinuance.^b Symptoms often occur without evidence of adrenal insufficiency (while plasma glucocorticoid concentrations were still high but were falling rapidly).^b

  
  


• 
  

  If used for only brief periods (a few days) in emergency situations, may reduce and discontinue dosage quite rapidly.^b

  
  


• 
  

  Very gradually withdraw systemic glucocorticoids until recovery of HPA-axis function occurs following long-term therapy with pharmacologic dosages.^{b g} (See Adrenocortical Insufficiency under Warnings.)

  
  


• 
  

  Exercise caution when transferring from systemic glucocorticoid to oral or nasal inhalation corticosteroid therapy.^b (See Conversion to Orally Inhaled Therapy in Patients Receiving Systemic Corticosteroids under Dosage and Administration.)

  
  


• 
  

  Many methods of slow withdrawal or “tapering” have been described.^b

  
  


• 
  

  In one suggested regimen, decrease by 2–4 mg every 3–7 days until the physiologic dose (4 mg) is reached.^b

  
  


• 
  

  Other recommendations state that decrements usually should not exceed 2 mg every 1–2 weeks.^b

  
  


• 
  

  When a physiologic dosage has been reached, single 20-mg oral morning doses of hydrocortisone can be substituted for whatever glucocorticoid the patient has been receiving.^b After 2–4 weeks, may decrease hydrocortisone dosage by 2.5 mg every week until a single morning dosage of 10 mg daily is reached.^b

  
  


• 
  

  For certain acute allergic conditions (e.g., contact dermatitis such as poison ivy) or acute exacerbations of chronic allergic conditions, glucocorticoids may be administered short term (e.g., for 6 days).^b Administer an initially high dose on the first day of therapy, and then withdraw therapy by tapering the dose over several days.^b

  
  

Conversion to Orally Inhaled Therapy in Patients Receiving Systemic Corticosteroids

• 
  

  When switching from systemic corticosteroids to orally inhaled triamcinolone acetonide in patients with asthma, asthma should be reasonably stable before initiating treatment with the oral inhalation.^a

  
  


• 
  

  Initially, administer the aerosol concurrently with the maintenance dosage of the systemic corticosteroid.^a After about 1 week, gradually withdraw systemic corticosteroid by reducing the daily or alternate daily dosage.^{a c} Generally, decrease dosage in decrements of ≤2 mg of triamcinolone acetonide after intervals of 1–2 weeks, depending on patient response.^{a b}

  
  


• 
  

  Death has occurred in some individuals in whom systemic corticosteroids were withdrawn too rapidly.¹⁰⁵ (See Adrenocortical Insufficiency under Warnings.)

  
  


• 
  

  During withdrawal of oral therapy, symptoms of systemic corticosteroid withdrawal may occur, despite maintenance or even improvement in pulmonary function;^a continue oral inhalation therapy but monitor for objective signs of adrenal insufficiency.^a If evidence of adrenal insufficiency occurs, increase systemic corticosteroid dosage temporarily and then continue withdrawal more slowly.^a

  
  


• 
  

  If exacerbations of asthma occur during oral inhalation therapy after systemic corticosteroids have been withdrawn, administer short courses of systemic corticosteroids, then taper dosage as symptoms subside.^c Supplemental systemic corticosteroid therapy may also be required during periods of stress.^a

  
  

Administration

Administer orally,^j by oral inhalation,^a or by IM injection.^{c d} Not for IV injection.^{d e g h}

Administer for local effect by intra-articular, intrabursal, intrasynovial, intralesional (intradermal), sublesional, soft-tissue, or epidural injection.^{b c d e g h}

Generally reserve IM therapy for patients who are not able to take the drug orally.^{c d}

Oral Administration

Triamcinolone

Administer orally as tablets.^j

Oral Inhalation

Triamcinolone Acetonide

Prime inhaler prior to first use and after a period of nonuse >3 days by shaking upright inhaler gently and then pressing the canister firmly (away from eyes) and quickly to release spray; repeat procedure so a total of 2 sprays are released.^a

Shake well immediately before each use and invert inhaler prior to actuation.^{a c} Exhale as completely as possible and place the mouthpiece of the inhaler well into the mouth with lips closed firmly around it.^{a c} Inhale slowly and deeply through the mouth while pressing the metal canister down with the forefinger.^{a c} After holding the breath for as long as possible (about 10 seconds), remove the mouthpiece and exhale very slowly.^{a c} If additional inhalations are required, wait ≥1 minute between inhalations, shake the inhaler again, and repeat the procedure.^{a c}

Following each treatment, rinse mouth thoroughly with water or mouthwash^c to remove drug deposited in the oropharyngeal area.^{a c}

Clean inhaler once daily by removing canister from the inhaler, pulling apart the 2 plastic parts of inhaler, removing mouthpiece cap, and gently washing in lukewarm water; dry thoroughly.^a

IM Administration

Triamcinolone Acetonide

Administer 40-mg/mL sterile suspension by deep IM injection into gluteal muscle.^d The 10-mg/mL sterile suspension is not suitable for IM administration.^e

Shake vial before use to insure uniform suspension.^d For adults, a minimum needle length of 1.5 inches recommended; a longer needle may be required in obese patients.^d Use alternate sites for subsequent injections.^d

Because it is slowly absorbed, IM administration is not indicated when an immediate effect or short duration is required.^c

Do not administer IM for conditions prone to bleeding (e.g., ITP).^d

Intra-articular, Intrabursal, Intrasynovial, Intralesional, or Soft-tissue Administration

For treatment of joints, consult standard textbooks for administration techniques.^{d e}

Triamcinolone Acetonide

Administer by intra-articular, intrabursal, intrasynovial, soft-tissue, intralesional, or sublesional injection.^{c d e}

Shake vial before use to insure uniform suspension.^{d e}

For intralesional (or sublesional) injection, use the 10-mg/mL sterile suspension;^e the-40 mg/mL sterile suspension is not intended for intralesional (intradermal) use.^d

Use a tuberculin syringe to facilitate intralesional or sublesional dosage measurement.^c May inject multiple sites if they are ≥1 cm apart.^c

For intra-articular, intrabursal, intrasynovial, or soft-tissue injection, may use either the 10- or 40-mg/mL sterile suspension.^c A local anesthetic (e.g., procaine hydrochloride) may be infiltrated into soft tissue surrounding the joint and/or injected into the joint before administration of triamcinolone acetonide.^{c d}

Triamcinolone Hexacetonide

Administer by intra-articular, soft-tissue, intralesional, or sublesional injection.^{c g h}

For intralesional (or sublesional) injection, use the 5-mg/mL sterile suspension.^{c h} For intra-articular or soft-tissue injection, use the 20-mg/mL sterile suspension.^g

Dilution of Triamcinolone Hexacetonide

May dilute with a local anesthetic (e.g., 1% or 2% lidocaine hydrochloride) prior to intra-articular or intralesional injection.^{c g h} May dilute with sterile water for injection, 0.9% sodium chloride injection, or 5 or 10% dextrose in 0.9% sodium chloride injection prior to intralesional injection.^{c h}

Determine optimum dilution by nature and location of lesion, lesion size, depth of injection, and necessary volume; generally, perform more superficial injections with greater dilution.^h

Avoid diluents containing preservatives (e.g., parabens, phenols).^{g h}

Epidural Administration

Long-acting injectable suspension has been administered by epidural injection, although safety of epidural injections using preserved formulations is controversial and epidural administration of these formulations is not recommended by the manufacturer.^b Limited evidence suggests that large particles in glucocorticoid suspensions may cause embolic vascular occlusion following inadvertent intra-arterial injection.

Inject into the epidural space near the site where the nerve roots pass before entering the intervertebral foramen.

Epidural injections may be performed by caudal, interlaminar, or transforaminal approaches; the transforaminal approach requires the smallest injection volume and appears to be the most specific and possibly most effective route.

Because of the potential for complications related to improper needle placement or drug administration, many experts state that epidural injections should be performed by an experienced clinician using fluoroscopic guidance and contrast control to ensure that the needle is correctly positioned and that the injection is not performed intravascularly, intrathecally, or into tissues other than the epidural space.

Optimal technique, dosage, timing of initial injection, injection frequency, and maximum number of injections remain to be established.

Dosage

Available as triamcinolone, triamcinolone acetonide, and triamcinolone hexacetonide. Dosage of triamcinolone acetonide or hexacetonide is expressed in terms of the respective salt.^{d g}

Triamcinolone acetonide oral aerosol inhaler delivers about 100 mcg of drug per metered spray.^a Commercially available aerosol delivers at least 240 metered sprays;^{a c} do not use after 240 actuations.^{a c}

After a satisfactory response is obtained, decrease dosage in small decrements to the lowest level that maintains an adequate clinical response, and discontinue the drug as soon as possible.^{b c}

Monitor patients continually for signs that indicate dosage adjustment is necessary, such as remissions or exacerbations of the disease and stress (surgery, infection, trauma).^b

High dosages may be required for acute situations of certain rheumatic disorders and collagen diseases; after a response has been obtained, drug often must be continued for long periods at low dosage.^b

High or massive dosages may be required in the treatment of pemphigus, exfoliative dermatitis, bullous dermatitis herpetiformis, severe erythema multiforme, or mycosis fungoides.^b Early initiation of systemic glucocorticoid therapy may be life-saving in pemphigus vulgaris.^b Reduce dosage gradually to the lowest effective level, but discontinuance may not be possible.^b

Pediatric Patients

Base pediatric dosage on severity of the disease and patient response rather than on strict adherence to dosage indicated by age, body weight, or body surface area.^{c j}

Usual Dosage

Oral

Some clinicians recommend 0.117–1.66 mg/kg daily or 3.3–50 mg/m² daily, administered in 4 divided doses.^c

IM

Triamcinolone acetonide in children <6 years of age: Dosage not established; insufficient clinical experience to recommend use in this age group.^{c d}

Triamcinolone acetonide in children 6–12 years of age: Initially, 40 mg depending on the severity of the condition.^d Some clinicians recommend 0.03–0.2 mg/kg or 1–6.25 mg/m² at 1- to 7-day intervals.^c

Triamcinolone acetonide in children >12 years of age: Initially, 60 mg (using the 40-mg/mL sterile suspension).^{c d} May administer additional doses of 20–100 mg (usually 40–80 mg) when signs and symptoms recur; ^{c d} some clinicians recommend administration at 6-week intervals, if possible, to minimize HPA suppression.^c Some patients may be well controlled on doses ≤20 mg.^d

Intra-articular or Soft-tissue Injection

Triamcinolone hexacetonide: Initially, 0.11–1.6 mg/kg daily or 3.2–48 mg/m² daily, administered in 3–4 divided doses; dosage may vary depending on disease being treated.^g

Asthma

Oral Inhalation

Triamcinolone acetonide in children <6 years of age: manufacturer does not recommended use in this age group.¹⁰⁵

Triamcinolone acetonide in children 6–12 years of age: Initially, 100 or 200 mcg (1 or 2 sprays) 3 or 4 times daily (300–800 mcg total) or 200–400 mcg (2–4 sprays) twice daily (400–800 mcg total); adjust dosage according to patient response.¹⁰⁵ Maximum dosage recommended by manufacturer is 1200 mcg (12 sprays) daily;¹⁰⁵ some experts state that higher dosages may be used in children with severe persistent asthma.^{102 104}

Continually monitor patients for signs that indicate dosage adjustment is necessary (e.g., remissions or exacerbations of disease and stress [surgery, infection, trauma]).^{c j} (See Conversion to Orally Inhaled Therapy in Patients Receiving Systemic Corticosteroids under Dosage and Administration.)

Neoplastic Diseases

Oral

In children with acute leukemia, usually 1 mg/kg daily, but up to 2 mg/kg may be necessary.^j Initial response usually observed within 6–21 days and therapy continued for 4–6 weeks.^j

Adults

Usual Dosage

Oral

Initially, 4–48 mg daily, usually administered in 1–4 doses, depending on disease being treated.^j

IM

Triamcinolone acetonide: Usually, 60 mg (using the 40-mg/mL sterile suspension).^{c d} May administer additional doses of 20–100 mg (usually 40–80 mg) when signs and symptoms recur.^{c d} Some clinicians recommend administration at 6-week intervals, if possible, to minimize HPA suppression.^c Some patients may be well controlled with doses ≤20 mg.^d

Intra-articular, Intrabursal, Intrasynovial, or Soft-tissue Injection

Dosage varies depending on location, size, and degree of inflammation.^{b d e}

Triamcinolone acetonide: Initially, 5–15 mg for large joints; 2.5–5 mg for small joints.^{c d e} Symptom relief generally occurs with dosages ≤40 mg for large joints and ≤10 mg for small joints.^{d e} For soft-tissue injection in treatment of tendon sheath inflammation, 2.5–10 mg.^c Repeat when signs and symptoms recur.^{b d e}

Intra-articular or Soft-tissue Injection

Dosage varies depending on location, size, and degree of inflammation.^{c g}

Triamcinolone hexacetonide: 10–20 mg for large joints; 2–6 mg for small joints.^{c g} Determine subsequent dosage and frequency based on patient response.^{c g} Repeat every 3–4 weeks as necessary; more frequent administration is not recommended.^{c g}

Intralesional or Sublesional Injection

Dosage varies depending on location, size, and degree of inflammation.^{d e}

Triamcinolone acetonide: ≤1 mg per injection site; may repeat at intervals of ≥1 week, depending on patient response.^{c e} May inject intralesionally into multiple sites if ≥1 cm apart, but do not exceed total dosage of 30 mg at any one time.^c

Triamcinolone hexacetonide: average dose ≤0.5 mg per square inch of affected skin.^h Administer additional injections according to patient response.^c

Asthma

Oral Inhalation

Triamcinolone acetonide: Initially, 200 mcg (2 sprays) 3 or 4 times daily (600 or 800 mcg total) or 400 mcg (4 sprays) twice daily.^a In adults with severe asthma, it may be advisable to start with 12–16 sprays daily (1200–1600 mcg total), and then reduce dosage to the lowest effective level.^a Maximum 1600 mcg (16 sprays) daily recommended by manufacturer,¹⁰⁵ but some experts state that higher dosages may be used.^{100 102 a}

Oral

For severe or incapacitating asthma, 8–16 mg daily.^j

Adrenocortical Insufficiency

Oral

Usually, 4–12 mg daily in addition to mineralocorticoid therapy.^j

Rheumatic Disorders and Collagen Diseases

Oral

In patients with rheumatoid arthritis, acute gouty arthritis, ankylosing spondylitis, select cases of psoriatic arthritis, acute and subacute bursitis, or acute nonspecific tenosynovitis, initially, 8–16 mg once daily (morning) or on alternate days.^j Occasionally, more effective relief achieved with administration 2–4 times daily.^j

In patients with systemic lupus erythematosus, initially, 20–32 mg daily until desired response is achieved, then reduce to maintenance dosage.^j In patients with more severe symptoms, ≥48 mg daily initially and higher maintenance dosages may be required.