Triamcinolone (Systemic) (Lexi-Drugs)

Pronunciation

(trye am SIN oh lone)

Brand Names: US

Arze-Ject-A [DSC]; Kenalog; P-Care K40; P-Care K80; Pod-Care 100K; Pro-C-Dure 5; Pro-C-Dure 6; ReadySharp Triamcinolone [DSC]; Zilretta

Brand Names: Canada

Aristospan [DSC]; Kenalog-10; Kenalog-40

Pharmacologic Category

Corticosteroid, Systemic

Dosing: Adult

Note: Aristospan Intra-Articular has been discontinued in the United States for more than 1 year.

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 (Aristospan 20 mg/mL): 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

Pericarditis (off-label use): Intrapericardial (off-label route): 300 mg/m2 as a single dose (Maisch 2002) or 50 mg every 6 hours for 2 to 3 days (ESC [Maisch 2004]); may use in conjunction with oral colchicine therapy. Administration may be painful and appropriate analgesic premedication (eg, morphine) should be administered (Frasiolas 2010; Maisch 2002). Additional data may be necessary to further define the role of triamcinolone in this condition.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Renal Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling; use with caution.

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling; use with caution.

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

Dosing: Renal Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer’s labeling.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer’s labeling.

Use: Labeled Indications

Intra-articular or soft tissue administration: As adjunctive therapy for short-term administration in acute gout flares, acute and subacute bursitis, acute nonspecific tenosynovitis, epicondylitis, rheumatoid arthritis (RA), or synovitis of osteoarthritis; management of osteoarthritis (OA) knee pain.

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.

Use: Off-Label: Adult

  PericarditisLevel of Evidence [C, G]

Intrapericardial glucocorticoid therapy to achieve high local glucocorticoid concentrations may maintain efficacy while minimizing systemic toxicity. European Society of Cardiology guidelines state that intrapericardial glucocorticoid therapy may be considered Ref.

Level of Evidence Definitions
  Level of Evidence Scale
Clinical Practice Guidelines

Gout:

3e Initiative, Guidelines for the Management of Gout, 2014

American College of Rheumatology (ACR), Guidelines for the Management of Hyperuricemia, 2012

BSR/BHPR, Guideline for the Management of Gout, 2007

Juvenile Idiopathic Arthritis:

American College of Rheumatology, “2013 Update of the 2011 American College of Rheumatology Recommendations for the Treatment of Juvenile Idiopathic Arthritis,” 2013

Administration: IM

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

Kenalog-40 injection: For 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.

Administration: Other

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 or soft tissue administration.

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: Dilute with a compatible solution prior to administration.

Aristospan (20 mg/mL): For intra-articular and soft tissue administration only; use a ≥23-gauge needle

Intrapericardial (off-label route): Triamcinolone hexacetonide: Instillation of triamcinolone suspension (diluted in 100 mL of warm [37°C] NS) may be administered as a slow injection over a 7F pigtail catheter introduced after pericardiocentesis; may be painful and appropriate analgesic premedication (eg, morphine) should be administered (Frasiolas 2010; Maisch 2002).

Administration: Pediatric

Parenteral: 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. Dilute hexacetonide injection with a compatible solution prior to administration.

Acetonide:

Kenalog-10 injection: For intra-articular or intralesional administration only. When administered intralesionally, inject directly into the lesion (ie, intradermally or subcutaneously). Tuberculin syringes with a 23- to 25-gauge needle are preferable for intralesional injections. For infantile hemangioma, 27- and 30-gauge needles have been used (Chen 2000; Prasetyono 2011).

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 for adults. Obese patients may require a longer needle. Alternate sites for subsequent injections. Avoid IM injections into deltoid area.

Hexacetonide:

Aristospan (5 mg/mL): For intralesional or sublesional administration only; use a ≥23-gauge needle

Aristospan (20 mg/mL): For intra-articular and soft tissue administration only; use a ≥23-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/Stability

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: Store at 20°C to 25°C (68°F to 77°F); avoid freezing. Protect from light. Diluted suspension stable up to 1 week.

Preparation for Administration: Adult

Hexacetonide injectable suspension: 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).

Intrapericardial (off-label route) administration: Triamcinolone hexacetonide dose should be diluted in at least 100 mL of warm (37°C) NS (Frasiolas 2010).

Preparation for Administration: Pediatric

Hexacetonide injectable suspension: Shake well before use to ensure suspension is uniform. Inspect visually to ensure no clumping; avoid diluents containing parabens, phenol, or other preservatives (may cause flocculation). Suspension for intralesional (5 mg/mL) administration may be diluted with D5NS, D10NS, NS, or SWFI to a 1:1, 1:2, or 1:4 concentration. Solutions for intra-articular (20 mg/mL) administration may be diluted with lidocaine 1% or 2%.

Medication Patient Education with HCAHPS Considerations

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience nausea, vomiting, insomnia, agitation, or hair thinning. Have patient report immediately to prescriber signs of infection, signs of high blood sugar (confusion, fatigue, increased thirst, increased hunger, polyuria, flushing, fast breathing, or breath that smells like fruit), signs of Cushings disease (weight gain in upper back or abdomen; moon face; severe headache; or slow healing), signs of adrenal gland problems (severe nausea, vomiting, severe dizziness, passing out, muscle weakness, severe fatigue, mood changes, lack of appetite, or weight loss), signs of low potassium (muscle pain or weakness, muscle cramps, or an abnormal heartbeat), severe abdominal pain, loss of strength and energy, irritability, tremors, tachycardia, 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 edema, vision changes, mood changes, behavioral changes, depression, menstrual changes, seizures, burning or numbness feeling, injection site redness or edema, signs of skin changes (acne, stretch marks, slow healing, or hair growth), or black, tarry, or bloody stools (HCAHPS).

• Educate patient about signs of a significant reaction (eg, 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. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.

Medication Safety Issues
  Sound-alike/look-alike issues:
  Other safety concerns:
Contraindications

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

Additional contraindication: Zilretta: Hypersensitivity to corticosteroids.

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.

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).

Geriatric Considerations

Because of the risk of adverse effects, corticosteroids should be used cautiously in the elderly, in the smallest possible dose, and for the shortest possible time.

Warnings: Additional Pediatric Considerations

Adrenal suppression with failure to thrive has been reported in infants and young children receiving intralesional corticosteroid injections for the treatment of infantile hemangioma; failure to gain weight may persist until HPA axis recovers; time to recovery of adrenal function may be prolonged (mean: 19.5 weeks; range 4 to 65 weeks) (DeBoer, 2008; Morkane, 2011). May cause osteoporosis (at any age) or inhibition of bone growth in pediatric patients. Use with caution in patients with osteoporosis. In a population-based study of children, risk of fracture was shown to be increased with >4 courses of corticosteroids; underlying clinical condition may also impact bone health and osteoporotic effect of corticosteroids (Leonard, 2007). Tissue atrophy at the site of IM injection has been reported; avoid intramuscular injections into the deltoid area. Cutaneous atrophy was reported in 2.5% of pediatric patients when given intra-articularly (Bloom, 2011). Prevention of periarticular subcutaneous atrophy via injecting small amounts of saline into the joint and applying pressure following the injection has been recommended (Hashkas, 2005).

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).

Breast-Feeding Considerations

Corticosteroids are present in breast milk.

The manufacturer notes that when used systemically, maternal use of corticosteroids have the potential to cause adverse events in a breastfeeding infant (eg, growth suppression, interfere with endogenous corticosteroid production); therefore, caution should be used if administered to a breastfeeding female. A case report notes a decrease in milk production following a high-dose triamcinolone injection in a breastfeeding mother with a previously abundant milk supply (McGuire 2012).

Corticosteroids are generally considered acceptable in breastfeeding females when used in usual doses (Götestam Skorpen 2016; WHO 2002); however, monitoring of the breastfeeding infant is recommended (WHO 2002). If there is concern about exposure to the infant, some guidelines recommend waiting 4 hours after the maternal dose of an oral systemic corticosteroid before breastfeeding in order to decrease potential exposure to the breastfeeding infant (based on a study using prednisolone) (Bae 2012; Butler 2014; Götestam Skorpen 2016; Leachman 2006; Makol 2011; Ost 1985).

Briggs’ Drugs in Pregnancy & Lactation
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, increased intracranial pressure, insomnia, malaise, meningitis, mood changes, myasthenia, neuritis, neuropathy, paraplegia, paresthesia, personality changes, pseudotumor cerebri (upon discontinuation), psychiatric disturbance, quadriplegia, seizure, spinal cord infarction, vertigo

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

Endocrine & metabolic: Calcinosis, cushingoid state, decreased glucose tolerance, decreased serum potassium, diabetes mellitus, fluid retention, glycosuria, growth suppression, 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, petechiae

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

Allergy and Idiosyncratic Reactions
Metabolism/Transport Effects

Substrate of CYP3A4 (minor); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential

Drug Interactions 

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

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

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

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

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

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

Antihepaciviral Combination Products: May increase the serum concentration of Triamcinolone (Systemic). Risk C: 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. Risk D: 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. Risk D: 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. Risk D: Consider therapy modification

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

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

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

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

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

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

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

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

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

Denosumab: May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased. Risk C: 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. Risk D: Consider therapy modification

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

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

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

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

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

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). Risk D: Consider therapy modification

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

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

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

Isoniazid: Corticosteroids (Systemic) may decrease the serum concentration of Isoniazid. Risk C: 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. Risk D: Consider therapy modification

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

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

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. Risk X: Avoid combination

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

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

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

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

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

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

Nivolumab: Immunosuppressants may diminish the therapeutic effect of Nivolumab. Risk D: 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). Risk C: Monitor therapy

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

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

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

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

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

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

Roflumilast: May enhance the immunosuppressive effect of Immunosuppressants. Risk D: 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. Risk C: Monitor therapy

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

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

Sipuleucel-T: Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Risk C: Monitor therapy

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

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

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

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

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

Thiazide and Thiazide-Like Diuretics: Corticosteroids (Orally Inhaled) may enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics. Risk C: 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). Risk D: Consider therapy modification

Tobacco (Smoked): May diminish the therapeutic effect of Corticosteroids (Orally Inhaled). Risk C: 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. Risk D: Consider therapy modification

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

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.Risk C: 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. Risk D: 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. Risk D: Consider therapy modification

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

Monitoring Parameters

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

Advanced Practitioners Physical Assessment/Monitoring

Patients with diabetes should monitor glucose levels closely (corticosteroids may alter glucose levels). When used for >10 to 14 days, do not discontinue abruptly; decrease dosage incrementally.

Nursing Physical Assessment/Monitoring

Patients with diabetes should monitor glucose levels closely (corticosteroids may alter glucose levels). When used for >10 to 14 days, do not discontinue abruptly; decrease dosage incrementally.

Product Availability

Aristospan Intra-Articular has been discontinued in the United States for more than 1 year.

Dosage Forms: US

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]

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]

Dosage Forms: Canada

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

Suspension, Injection:

Generic: 40 mg/mL (5ml)

Suspension, Injection, as acetonide:

Kenalog-10: 10 mg/mL (5ml)

Kenalog-40: 40 mg/mL (1ml, 5ml)

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

Suspension, Injection, as hexacetonide:

Aristospan: 20 mg/mL (1ml[DSC], 5ml[DSC])

Generic: 20 mg/mL (1ml)

Anatomic Therapeutic Chemical (ATC) Classification
  • A01AC01
  • H02AB08
Generic Available (US)

May be product dependent

Pricing: US

Kit (Pro-C-Dure 5 Injection)

2 X 40 mg/mL (per each): $600.49

Kit (Pro-C-Dure 6 Injection)

3 X 40 mg/mL (per each): $736.45

Suspension (Kenalog Injection)

10 mg/mL (per mL): $2.90

40 mg/mL (per mL): $11.40

Suspension (Triamcinolone Acetonide Injection)

40 mg/mL (per mL): $10.20

Suspension Reconstituted ER (Zilretta Intra-articular)

32 mg (per each): $684.00

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer’s AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

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

Pharmacodynamics/Kinetics

Onset: Adrenal suppression: IM (acetonide): 24 to 48 hours; Intra-articular: 12 to 24 hours

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

Distribution: Vd: IV (acetonide): 99.5 L

Metabolism: Hepatic (Asare 2007)

Half-life elimination: Plasma: 300 minutes (Asare 2007)

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

Dental Use

Adjunctive treatment and temporary relief of symptoms associated with oral inflammatory lesions and ulcerative lesions resulting from trauma

Local Anesthetic/Vasoconstrictor Precautions

No information available to require special precautions

Effects on Dental Treatment

Key adverse event(s) related to dental treatment: Ulcerative esophagitis, perioral dermatitis, atrophy of oral mucosa, burning, irritation, and oral monilia (oral inhaler).

Effects on Bleeding

No information available to require special precautions

Index Terms

Triamcinolone Acetonide; Triamcinolone Acetonide, Parenteral; Triamcinolone Hexacetonide

FDA Approval Date
January 04, 1960
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Zhang W, Doherty M, Bardin T, et al; EULAR Standing Committee for International Clinical Studies Including Therapeutics. EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2006;65(10):1312-1324.[PubMed 16707532]

Zilretta (triamcinolone acetonide) [prescribing information]. Burlington, MA: Flexion Therapeutics Inc; May 2018.

Zulian F, Martini G, Gobber D, Agosto C, Gigante C, Zacchello F. Comparison of intra-articular triamcinolone hexacetonide and triamcinolone acetonide in oligoarticular juvenile idiopathic arthritis. Rheumatology. 2003;42(10):1254-1259.[PubMed 12810938]

Zulian F, Martini G, Gobber D, Plebani M, Zacchello F, Manners P. Triamcinolone acetonide and hexacetonide intra-articular treatment of symmetrical joints in juvenile idiopathic arthritis: a double-blind trial. Rheumatology (Oxford). 2004;43(10):1288-1291.[PubMed 15252213]

Brand Names: International

Acetidrona (UY); Aftab (DE); Albicort (BE); Amcinol (EG); Aristocort (BD); Aristocort A (TH); Atrinat (CL); Avcort (IN); Bluxam (ES, PT); Cenalog (UA); Cenolon (BD, LK); Cynocort (BD); Danizax (VN); Delphicort (AT); Deltrianolona (CO); Epirelefan (EG); Flamicort (ID); Forticinolone (AR); Intralon (CR, DO, GT, HN, NI, SV); Introlan (PA); Ioncort (UY); Kenacort (EG, IN, MX, NO, VE, VN); Kenacort A (AE, BE, CH, KW, LK, SA); Kenacort E (PE); Kenacort IM (PE); Kenacort Retard (FR); Kenacort T (NO); Kenacort-A (AU, ID, LU, NZ, PE); Kenacort-A I.M. (CO); Kenalog (DK, EE, GB, HR, HU, LT, LV); Kenalog-40 (BB, SG); Kilcort (ET); Konicort (ID); Ledercort (AE, IN, JO, KR); Lederlon (DE); Lederspan (AE, FI); Loncort (IN); MaQaid (JP); Maquaid (KR); Oracort (IL); Panbicort (JO); Polkortolon (UA); Rabeolone (VN); Rheudenolone (KR); Shincort (HK, MY, PH, SG, TH); Sivkort (MY); Softram (MX); Solu-Volon (AT); Sterocort (IL); Stucort (IN); T-Cort (BD); Thainocort (TH); Tracinone (KR); Tramsicort (MX); Trecilon (BD); Tri-Ject (IN); Triam (DE, KR); Triamcort (AR); TriamHEXAL (DE); Triamhexal (TR); Triamon (BD); Trica (NO); Tricort (ET); Trigon Depot (ES); Trilac (ID, PH); Trimcort (BD); Trinakor (CO); Trincort (LK); Trispan (HK); Trispane (AT); Volon A (AT); Volon A 10 (DE); Volon A 40 (DE)

Triamcinolone (Systemic) (Patient Education – Adult Medication)
You must carefully read the “Consumer Information Use and Disclaimer” below in order to understand and correctly use this information
Pronunciation

(trye am SIN oh lone)

Brand Names: US

Arze-Ject-A [DSC]; Kenalog; P-Care K40; P-Care K80; Pod-Care 100K; Pro-C-Dure 5; Pro-C-Dure 6; ReadySharp Triamcinolone [DSC]; Zilretta

Brand Names: Canada

Aristospan; Kenalog

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.
What do I need to tell my doctor BEFORE I take this drug?
  • For all uses of this drug:
  • If you have an allergy to triamcinolone or any other part of this drug.
  • If you are allergic to any drugs like this one, any other drugs, foods, or other substances. Tell your doctor about the allergy and what signs you had, like rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other signs.
  • If you have any stomach or bowel problems like diverticulitis, diverticulosis, ulcerative colitis, or ulcers.
  • If you have any of these health problems: A fungal infection or malaria infection in the brain.
  • If you have a herpes infection of the eye.
  • If you have an infection where the shot will be given.
  • Injection (if given in the muscle):
  • If you have idiopathic thrombocytopenic purpura (ITP).
  • This is not a list of all drugs or health problems that interact with this drug.
  • Tell your doctor and pharmacist about all of your drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe for you to take this drug with all of your drugs and health problems. Do not start, stop, or change the dose of any drug without checking with your doctor.
What are some things I need to know or do while I take this drug?
  • All products:
  • Tell all of your health care providers that you take this drug. This includes your doctors, nurses, pharmacists, and dentists.
  • Very bad and sometimes deadly allergic reactions have rarely happened. Talk with your doctor.
  • If you have high blood sugar (diabetes), you will need to watch your blood sugar closely.
  • Tell your doctor if you have signs of high blood sugar like confusion, feeling sleepy, more thirst, more hungry, passing urine more often, flushing, fast breathing, or breath that smells like fruit.
  • You may have more chance of getting an infection. Wash hands often. Stay away from people with infections, colds, or flu.
  • Chickenpox and measles can be very bad or even deadly in some people taking steroid drugs like this drug. Avoid being near anyone with chickenpox or measles if you have not had these health problems before. If you have been exposed to chickenpox or measles, talk with your doctor.
  • This drug may lower how much natural steroid is in your body. If you have a fever, an infection, surgery, or you are hurt, talk with your doctor. You may need extra doses of oral steroids. These extra steroids will help your body deal with these stresses. Carry a warning card saying that there may be times when you need extra steroids.
  • Talk with your doctor before getting any vaccines. Use of some vaccines with this drug may either raise the chance of an infection or make the vaccine not work as well.
  • Very bad health problems have happened when drugs like this one have been given into the spine (epidural). These include paralysis, loss of eyesight, stroke, and sometimes death. It is not known if drugs like this one are safe and effective when given into the spine. These drugs are not approved for this use. Talk with the doctor.
  • If you are 65 or older, use this drug with care. You could have more side effects.
  • Tell your doctor if you are pregnant or plan on getting pregnant. You will need to talk about the benefits and risks of using this drug while you are pregnant.
  • Tell your doctor if you are breast-feeding. You will need to talk about any risks to your baby.
  • All products other than Zilretta:
  • If you have been taking this drug for many weeks, talk with your doctor before stopping. You may want to slowly stop this drug.
  • This drug may cause weak bones (osteoporosis) with long-term use. Talk with your doctor to see if you have a higher chance of weak bones or if you have any questions.
  • Long-term use may raise the chance of cataracts or glaucoma. Talk with the doctor.
  • Use with care in children. Talk with the doctor.
  • Some products have benzyl alcohol. Do not give a product that has benzyl alcohol in it to a newborn or infant. Talk with the doctor to see if this product has benzyl alcohol in it.
  • This drug may affect growth in children and teens in some cases. They may need regular growth checks. Talk with the doctor.
What are some side effects that I need to call my doctor about right away?
  • WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:
  • All products:
  • Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
  • Signs of infection like fever, chills, very bad sore throat, ear or sinus pain, cough, more sputum or change in color of sputum, pain with passing urine, mouth sores, or wound that will not heal.
  • Signs of Cushing’s disease like weight gain in the upper back or belly, moon face, very bad headache, or slow healing.
  • Signs of a weak adrenal gland like a very bad upset stomach or throwing up, very bad dizziness or passing out, muscle weakness, feeling very tired, mood changes, not hungry, or weight loss.
  • Signs of high blood pressure like very bad headache or dizziness, passing out, or change in eyesight.
  • Signs of low potassium levels like muscle pain or weakness, muscle cramps, or a heartbeat that does not feel normal.
  • Shortness of breath, a big weight gain, or swelling in the arms or legs.
  • Very bad belly pain.
  • Black, tarry, or bloody stools.
  • Throwing up blood or throw up that looks like coffee grounds.
  • Any unexplained bruising or bleeding.
  • Bone pain.
  • Joint pain or swelling.
  • Feeling tired or weak.
  • Redness or white patches in mouth or throat.
  • Change in eyesight.
  • Mental, mood, or behavior changes that are new or worse.
  • Low mood (depression).
  • Period (menstrual) changes.
  • Seizures.
  • Skin changes (pimples, stretch marks, slow healing, hair growth).
  • A burning, numbness, or tingling feeling that is not normal.
  • Redness or swelling where the shot is given.
  • All products other than Zilretta:
  • Feeling very tired, weak, or touchy; trembling; having a fast heartbeat, confusion, sweating, or dizziness if you missed a dose or recently stopped this drug.
What are some other side effects of this drug?
  • All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:
  • All products:
  • Not able to sleep.
  • All products other than Zilretta:
  • Upset stomach or throwing up.
  • Weight gain.
  • Restlessness.
  • Sweating a lot.
  • Hair thinning.
  • These are not all of the side effects that may occur. If you have questions about side effects, call your doctor. Call your doctor for medical advice about side effects.
  • You may report side effects to your national health agency.
How is this drug best taken?
  • Use this drug as ordered by your doctor. Read all information given to you. Follow all instructions closely.
  • Injection (when given in the knee):
  • It is given as a shot into the knee.
  • For other reasons:
  • It is given as a shot.
  • For all uses of this drug:
  • You may need to lower how much salt is in your diet and take extra potassium. Talk with your doctor.
  • This drug may affect certain lab tests. Tell all of your health care providers and lab workers that you take this drug.
  • Have blood work checked as you have been told by the doctor. Talk with the doctor.
  • Have a bone density test as you have been told by your doctor. Talk with your doctor.
  • Have your eye pressure checked if you are on this drug for a long time. Talk with your doctor.
What do I do if I miss a dose?
  • Call your doctor to find out what to do.
How do I store and/or throw out this drug?
  • If you need to store this drug at home, talk with your doctor, nurse, or pharmacist about how to store it.
General drug facts
  • If your symptoms or health problems do not get better or if they become worse, call your doctor.
  • Do not share your drugs with others and do not take anyone else’s drugs.
  • Keep a list of all your drugs (prescription, natural products, vitamins, OTC) with you. Give this list to your doctor.
  • Talk with the doctor before starting any new drug, including prescription or OTC, natural products, or vitamins.
  • Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets.
  • Throw away unused or expired drugs. Do not flush down a toilet or pour down a drain unless you are told to do so. Check with your pharmacist if you have questions about the best way to throw out drugs. There may be drug take-back programs in your area.
  • Some drugs may have another patient information leaflet. If you have any questions about this drug, please talk with your doctor, nurse, pharmacist, or other health care provider.
  • If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.
Triamcinolone (Systemic) (Patient Education – Pediatric Medication)
You must carefully read the “Consumer Information Use and Disclaimer” below in order to understand and correctly use this information
Pronunciation

(trye am SIN oh lone)

Brand Names: US

Arze-Ject-A [DSC]; Kenalog; P-Care K40; P-Care K80; Pod-Care 100K; Pro-C-Dure 5; Pro-C-Dure 6; ReadySharp Triamcinolone [DSC]; Zilretta

Brand Names: Canada

Aristospan; Kenalog

What is this drug used for?
  • 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.
  • Injection (when given in the knee):
  • If your child has been given this form of this drug, talk with the doctor for information about the benefits and risks. Talk with the doctor if you have questions or concerns about giving this drug to your child.
What do I need to tell the doctor BEFORE my child takes this drug?
  • All products:
  • If your child has an allergy to this drug or any part of this drug.
  • If your child is allergic to any drugs like this one or any other drugs, foods, or other substances. Tell the doctor about the allergy and what signs your child had, like rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other signs.
  • If your child has any stomach or bowel problems like diverticulitis, diverticulosis, ulcerative colitis, or ulcers.
  • If your child has any of these health problems: A fungal infection or malaria infection in the brain.
  • If your child has a herpes infection of the eye.
  • If your child has an infection where the shot will be given.
  • Injection (if given in the muscle):
  • If your child has idiopathic thrombocytopenic purpura (ITP).
  • This is not a list of all drugs or health problems that interact with this drug.
  • Tell the doctor and pharmacist about all of your child’s drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe for your child to take this drug with all of his/her drugs and health problems. Do not start, stop, or change the dose of any drug your child takes without checking with the doctor.
What are some things I need to know or do while my child takes this drug?
  • Tell all of your child’s health care providers that your child is taking this drug. This includes your child’s doctors, nurses, pharmacists, and dentists.
  • Very bad and sometimes deadly allergic side effects have rarely happened. Talk with your child’s doctor.
  • Have blood work checked as you have been told by the doctor. Talk with the doctor.
  • Long-term use may raise the chance of cataracts, glaucoma, or weak bones (osteoporosis). Talk with your child’s doctor.
  • Your child may need to have a bone density test. Talk with the doctor.
  • Have your child’s eye pressure checked if your child is on this drug for a long time. Talk with the doctor.
  • If your child has high blood sugar (diabetes), you will need to watch his/her blood sugar closely.
  • Your child may have more chance of getting infections. Have your child wash hands often. Avoid crowds and people with infections, colds, or flu.
  • Chickenpox and measles can be very bad or even deadly in some people taking steroid drugs like this drug. Avoid having your child near anyone with chickenpox or measles if your child has not had these health problems before. If your child has been exposed to chickenpox or measles, talk with the doctor.
  • This drug may lower how much natural steroid is in your child’s body. If your child has a fever, an infection, surgery, or is hurt, talk with the doctor. Your child may need extra doses of oral steroids. These extra steroids will help your child’s body deal with these stresses. Carry a warning card saying that there may be times when your child needs extra steroids.
  • Talk with the doctor before your child gets any vaccines. Use of some vaccines with this drug may either raise the chance of very bad infection or make the vaccine not work as well.
  • If your child has been taking this drug for many weeks, talk with your child’s doctor before stopping. You may want to slowly stop this drug.
  • This drug may affect certain lab tests. Tell all of your child’s health care providers and lab workers that your child takes this drug.
  • You may need to lower how much salt is in your child’s diet and give your child extra potassium. Talk with your child’s doctor.
  • Some products have benzyl alcohol. Do not give a product that has benzyl alcohol in it to a newborn or infant. Talk with the doctor to see if this product has benzyl alcohol in it.
  • Very bad health problems have happened when drugs like this one have been given into the spine (epidural). These include paralysis, loss of eyesight, stroke, and sometimes death. It is not known if drugs like this one are safe and effective when given into the spine. These drugs are not approved for this use. Talk with the doctor.
  • Use with care in children. Talk with the doctor.
  • This drug may affect growth in children and teens in some cases. They may need regular growth checks. Talk with the doctor.
  • If your child is pregnant or breast-feeding a baby:
  • Talk with the doctor if your child is pregnant, becomes pregnant, or is breast-feeding a baby. You will need to talk about the benefits and risks to your child and the baby.
What are some side effects that I need to call my child’s doctor about right away?
  • WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your child’s doctor or get medical help right away if your child has any of the following signs or symptoms that may be related to a very bad side effect:
  • Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
  • Signs of infection like fever, chills, very bad sore throat, ear or sinus pain, cough, more sputum or change in color of sputum, pain with passing urine, mouth sores, or wound that will not heal.
  • Signs of high blood sugar like confusion, feeling sleepy, more thirst, more hungry, passing urine more often, flushing, fast breathing, or breath that smells like fruit.
  • Signs of Cushing’s disease like weight gain in the upper back or belly, moon face, very bad headache, or slow healing.
  • Signs of a weak adrenal gland like a very bad upset stomach or throwing up, very bad dizziness or passing out, muscle weakness, feeling very tired, mood changes, not hungry, or weight loss.
  • Signs of high blood pressure like very bad headache or dizziness, passing out, or change in eyesight.
  • Signs of low potassium levels like muscle pain or weakness, muscle cramps, or a heartbeat that does not feel normal.
  • Feeling very tired, weak, or touchy; trembling; having a fast heartbeat, confusion, sweating, or dizziness if a dose was missed or the drug was recently stopped.
  • A heartbeat that does not feel normal.
  • Shortness of breath, a big weight gain, or swelling in the arms or legs.
  • Very bad belly pain.
  • Black, tarry, or bloody stools.
  • Throwing up blood or throw up that looks like coffee grounds.
  • Any unexplained bruising or bleeding.
  • Redness or white patches in mouth or throat.
  • Bone pain.
  • Joint pain or swelling.
  • Feeling tired or weak.
  • Change in eyesight.
  • Mental, mood, or behavior changes that are new or worse.
  • Low mood (depression).
  • Seizures.
  • Skin changes (pimples, stretch marks, slow healing, hair growth).
  • A burning, numbness, or tingling feeling that is not normal.
  • Redness or swelling where the shot is given.
  • If your child has menstrual periods:
  • Period (menstrual) changes.
What are some other side effects of this drug?
  • All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your child’s doctor or get medical help if any of these side effects or any other side effects bother your child or do not go away:
  • Upset stomach or throwing up.
  • Weight gain.
  • Not able to sleep.
  • Restlessness.
  • Sweating a lot.
  • Hair thinning.
  • These are not all of the side effects that may occur. If you have questions about side effects, call your child’s doctor. Call your child’s doctor for medical advice about side effects.
  • You may report side effects to your national health agency.
How is this drug best given?
  • Give this drug as ordered by your child’s doctor. Read all information given to you. Follow all instructions closely.
  • It is given as a shot.
What do I do if my child misses a dose?
  • Call your child’s doctor to find out what to do.
How do I store and/or throw out this drug?
  • If you need to store this drug at home, talk with your child’s doctor, nurse, or pharmacist about how to store it.
General drug facts
  • If your child’s symptoms or health problems do not get better or if they become worse, call your child’s doctor.
  • Do not share your child’s drug with others and do not give anyone else’s drug to your child.
  • Keep a list of all your child’s drugs (prescription, natural products, vitamins, OTC) with you. Give this list to your child’s doctor.
  • Talk with your child’s doctor before giving your child any new drug, including prescription or OTC, natural products, or vitamins.
  • Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets.
  • Throw away unused or expired drugs. Do not flush down a toilet or pour down a drain unless you are told to do so. Check with your pharmacist if you have questions about the best way to throw out drugs. There may be drug take-back programs in your area.
  • Some drugs may have another patient information leaflet. If you have any questions about this drug, please talk with your child’s doctor, nurse, pharmacist, or other health care provider.
  • If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.