triamcinolone

triamcinolone

(trye am sin' oh lone)

triamcinolone

Oral:

Aristocort, Atolone

triamcinolone acetonide

IM, intra-articular, or soft-tissue injection; respiratory inhalant; dermatologic ointment, cream, lotion, aerosol:

Azmacort, Flutex, Kenaject 40, Kenalog, Nasacort, Nasacort AQ, Oracort (CAN), Tac-3, Tac-40, Triacet, Triamonide, Triam-A,Triderm, Tri-Kort, Trilog

triamcinolone hexacetonide

Intra-articular, intralesional injection:

Aristospan Intra-articular, Aristospan Intralesional

Pregnancy Category C

Drug classes

Corticosteroid (intermediate acting)

Glucocorticoid

Hormone

Therapeutic actions

Enters target cells and binds to cytoplasmic receptors, thereby initiating many complex reactions that are responsible for its anti-inflammatory and immunosuppressive effects.

Indications

·        Systemic: Hypercalcemia associated with cancer

·        Short-term management of various inflammatory and allergic disorders, such as rheumatoid arthritis, collagen diseases (eg, SLE), dermatologic diseases (eg,pemphigus), status asthmaticus, and autoimmune disorders

·        Hematologic disorders: Thrombocytopenia purpura, erythroblastopenia

·        Ulcerative colitis, acute exacerbations of MS, and palliation in some leukemias and lymphomas

·        Trichinosis with neurologic or myocardial involvement

·        Pulmonary emphysema with bronchial spasm or edema; diffuse interstitial pulmonary fibrosis; with diuretics in CHF with refractory edema and in cirrhosis with refractory ascites

·        Postoperative dental inflammatory reactions

·        Intra-articular, soft-tissue administration: Arthritis, psoriatic plaques, and so forth

·        Respiratory inhalant: Control of bronchial asthma requiring corticosteroids in conjunction with other therapy

·        Prophylactic therapy in the maintenance treatment of asthma (bid use)

·        Dermatologic preparations: To relieve inflammatory and pruritic manifestations of dermatoses that are steroid responsive

·        Nasal spray: Treatment of seasonal and perennial allergic-rhinitis symptoms in patients > 6 yr

Contraindications and cautions

·        Contraindicated with infections, especially tuberculosis, fungal infectons, amebiasis, vaccinia and varicella, and antibiotic-resistant infections; lactation.

·        Use cautiously with pregnancy (teratogenic in preclinical studies); renal or liver disease, hypothyroidism, ulcerative colitis with impending perforation,diverticulitis, active or latent peptic ulcer, inflammatory bowel disease, CHF, hypertension, thromboembolic disorders, osteoporosis, seizure disorders, diabetes mellitus.

Available forms

Tablets—1, 2, 4, 8 mg; syrup—4 mg/5 mL; injection—5, 20, 25, 40 mg/mL; aerosol—100 mcg/actuation; topical ointment—0.25, 0.1, 0.5%; cream—0.25, 0.1, 0.5%; lotion—0.025, 0.1%; nasal spray—50, 55 mcg/actuation

Dosages

ADULTS

Systemic

Individualize dosage, depending on the severity of the condition and the patient's response. Administer daily dose before 9 AM to minimize adrenal suppression. If long-term therapy is needed, consider alternate-day therapy. After long-term therapy, withdraw drug slowly to avoid adrenal insufficiency. For maintenance therapy, reduce initial dose in small increments at intervals until the lowest effective dose is reached.

Oral (triamcinolone)

·        Adrenal insufficiency: 4–12 mg/day, plus a mineralocorticoid.

·        Rheumatic, dermatologic, allergic, ophthalmologic, hematologic disorders and asthma: 8–60 mg/day.

·        TB meningitis: 32–48 mg/day.

·        Acute leukemia: 16–40 mg up to 100 mg/day.

IM (triamcinolone acetonide)

2.5–60 mg/day.

Respiratory inhalant (triamcinolone acetonide)

200 mcg released with each actuation delivers about 100 mcg to the patient. 2 inhalations tid–qid, not to exceed 16 inhalations/day.

Nasal spray

2 sprays (220 mcg total dose) in each nostril daily—maximum of 4 sprays/day.

ADULTS AND PEDIATRIC PATIENTS

Intra-articular, intralesional

Dose will vary with joint or soft-tissue site to be injected.

Triamcinolone acetonide: 2.5–15 mg.

Triamcinolone diacetate: 5–40 mg intra-articular; 5–48 mg intralesional; do not use > 12.5 mg per injection site or 25 mg per lesion.

Triamcinolone hexacetatonide: 2–20 mg intra-articular; up to 0.5 mg/square inch of affected area intralesional.

Topical dermatologic preparations

Apply sparingly to affected area bid–qid.

PEDIATRIC PATIENTS

Systemic

Individualize dosage, depending on the severity of the condition and the patient's response rather than by formulae that correct adult doses for age or body weight. Carefully observe growth and development in infants and children on prolonged therapy.

Oral (triamcinolone)

·        Acute leukemia: 1–2 mg/kg/day.

Respiratory inhalant (triamcinolone acetonide)

200 mcg released with each actuation delivers about 100 mcg to the patient.

6–12 yr: 1–2 inhalations tid–qid, not to exceed 12 inhalations/day.

Nasal spray

6–12 yr: One spray in each nostril once a day (110 mcg dose), maximum dose 2 sprays/nostril/day.

Topical dermatologic preparations

Apply low-potency form sparingly to affected area bid–qid.

Pharmacokinetics

Route	Onset	Peak	Duration
Oral	24–48 hr	1–2 hr	2.25 days
IM	24–48 hr	8–10 hr	1–6 wk

Metabolism: Hepatic; T_1/2: 2–5 hr

Distribution: Crosses placenta; enters breast milk

Excretion: Urine

Adverse effects

Effects depend on dose, route, and duration of therapy.

·        CNS: Vertigo, headache, paresthesias, insomnia, seizures, psychosis, cataracts, increased IOP, glaucoma (long-term therapy)

·        CV: Hypotension, shock, hypertension and CHF secondary to fluid retention, thromboembolism, thrombophlebitis, fat embolism, cardiac arrhythmias

·        Electrolyte imbalance: Na⁺ and fluid retention, hypokalemia, hypocalcemia

·        Endocrine: Amenorrhea, irregular menses, growth retardation, decreased carbohydrate tolerance, diabetes mellitus, cushingoid state (long-term effect), increased blood sugar, increased serum cholesterol, decreased T₃ and T₄ levels, hypothalamic-pituitary-adrenal (HPA) suppression with systemic therapy longer than 5 days

·        GI: Peptic or esophageal ulcer, pancreatitis, abdominal distention, nausea, vomiting, increased appetite, weight gain (long-term therapy)

·        Hypersensitivity: Hypersensitivity or anaphylactoid reactions

·        Musculoskeletal: Muscle weakness, steroid myopathy, loss of muscle mass, osteoporosis, spontaneous fractures (long-term therapy)

·        Other: Immunosuppression, aggravation, or masking of infections; impaired wound healing; thin, fragile skin; petechiae, ecchymoses, purpura, striae; subcutaneous fat atrophy

Intra-articular

·        Local: Osteonecrosis, tendon rupture, infection

Intralesional (face and head)

·        Local: Blindness (rare)

Respiratory inhalants

·        Local: Oral, laryngeal, and pharyngeal irritation; fungal infections

Topical dermatologic ointments, creams, sprays

·        Local: Local burning, irritation, acneiform lesions, striae, skin atrophy

Interactions

Drug-drug

·        Increased therapeutic and toxic effects with troleandomycin

·        Risk of severe deterioration of muscle strength when given to myasthenia gravis patients who are also receiving ambenonium, edrophonium, neostigmine,pyridostigmine

·        Decreased steroid blood levels with barbiturates, phenytoin, rifampin

·        Decreased effectiveness of salicylates

Drug-lab test

·        False-negative nitroblue-tetrazolium test for bacterial infection

·        Suppression of skin test reactions

Nursing considerations

Assessment

·        History: Infections; renal or liver disease; hypothyroidism; ulcerative colitis with impending perforation; diverticulitis; active or latent peptic ulcer; inflammatory bowel disease; CHF; hypertension; thromboembolic disorders; osteoporosis; seizure disorders; diabetes mellitus; pregnancy; lactation

·        Physical: Weight, T, reflexes and grip strength, affect and orientation, P, BP, peripheral perfusion, prominence of superficial veins, R, adventitious sounds, serum electrolytes, blood glucose

Interventions

·        Administer once-a-day doses before 9 AM to mimic normal peak corticosteroid blood levels.

·        Increase dosage when patient is subject to stress.

·        WARNING: Taper doses when discontinuing high-dose or long-term therapy to allow adrenal recovery.

·        Do not give live virus vaccines with immunosuppressive doses of corticosteroids.

·        WARNING: Taper systemic steroids carefully during transfer to inhalational steroids; deaths caused by adrenal insufficiency have occurred.

·        Use caution when occlusive dressings, tight diapers, and so forth cover affected area; these can increase systemic absorption when using topical preparations.

·        Avoid prolonged use of topical preparations near the eyes, in genital and rectal areas, and in skin creases.

Teaching points

·        Do not stop taking the drug without consulting your health care provider.

·        Avoid exposure to infections.

·        Report unusual weight gain, swelling of the extremities, muscle weakness, black or tarry stools, fever, prolonged sore throat, colds or other infections, worsening of your disorder.

Intra-articular administration

·        Do not overuse joint after therapy, even if pain is gone.

Respiratory inhalant

·        Do not use during an acute asthmatic attack or to manage status asthmaticus.

·        Do not use with systemic fungal infections.

·        Do not use more often than prescribed.

·        Do not stop using this drug without consulting your health care provider.

·        Administer inhalational bronchodilator drug first, if receiving concomitant bronchodilator therapy; rinse mouth after use.

Nasal spray

·        Do not spray in eyes.

·        Prime pump before first use and again if not used for > 2 weeks.

Topical dermatologic preparations

·        Apply drug sparingly, avoid contact with eyes.

·        Report irritation or infection at the site of application.

Adverse effects in Italic are most common; those in Bold are life-threatening.