AHFS Class:

• Adrenals 68:04

Generic Name(s):

• Triamcinolone

• Triamcinolone Acetonide

• Triamcinolone Hexacetonide

Triamcinolone is a synthetic glucocorticoid.

Triamcinolone is used principally as an anti-inflammatory or immunosuppressant agent. Because it has virtually no mineralocorticoid properties, the drug is inadequate alone for the management of adrenocortical insufficiency. If triamcinolone is used in the treatment of this condition, concomitant therapy with a mineralocorticoid is also required.

Asthma

Triamcinolone acetonide is used by oral inhalation for the long-term prevention of bronchospasm in patients with asthma.104,105

Orally inhaled triamcinolone acetonide should not be used for the primary treatment of severe acute asthmatic attacks or status asthmaticus when intensive measures (e.g., oxygen, parenteral bronchodilators, IV corticosteroids)104,105,109 are required. Triamcinolone acetonide oral inhaler is not a bronchodilator, and patients should be warned that the drug should not be used for rapid relief of bronchospasm.105

Mild Persistent Asthma

Drugs for asthma may be categorized as relievers (e.g., bronchodilators taken as needed for acute symptoms) or controllers (principally inhaled corticosteroids or other anti-inflammatory agents taken regularly to achieve long-term control of asthma).106,109 In the stepped-care approach to antiasthmatic drug therapy, current asthma management guidelines and most clinicians recommend initiation of a controller drug such as an anti-inflammatory agent, preferably a low-dose orally inhaled corticosteroid (e.g., 88-264, 88-176, or 176 mcg of fluticasone propionate [or its equivalent] daily via a metered-dose inhaler in adolescents and adults, children 5-11 years of age, or children 4 years of age or younger, respectively) as first-line therapy for persistent asthma (i.e., patients with daytime symptoms of asthma more than twice per week, but less than once daily, and nocturnal symptoms of asthma 3-4 times per month), supplemented by as-needed use of a short-acting, inhaled β₂-agonist.104,106,109 For equivalent orally inhaled dosages of corticosteroids, see General Dosage under Dosage and Administration: Dosage, in the Corticosteroids General Statement 68:04.

Moderate Persistent Asthma

According to current asthma management guidelines, therapy with a long-acting β₂-agonist such as salmeterol or formoterol generally is recommended in adults and adolescents who have moderate persistent asthma and daily asthmatic symptoms that are inadequately controlled following addition of low-dose inhaled corticosteroids to as-needed inhaled β₂-agonist treatment.106,109 However, the National Asthma Education and Prevention Program (NAEPP) recommends that the beneficial effects of long-acting inhaled β₂-agonists should be weighed carefully against the increased risk (although uncommon) of severe asthma exacerbations and asthma-related deaths associated with daily use of such agents.106 (See Asthma-related Death and Life-threatening Events under Cautions: Respiratory Effects, in Salmeterol 12:12.08.12.) Current asthma management guidelines also state that an alternative, but equally preferred option for management of moderate persistent asthma that is not adequately controlled with a low dosage of inhaled corticosteroid is to increase the maintenance dosage to a medium dosage (e.g., exceeding 264 but not more than 440 mcg of fluticasone propionate [or its equivalent] daily via a metered-dose inhaler in adults and adolescents).104,106,109

In children 5-11 years of age with moderate persistent asthma that is not controlled with a low dosage of an inhaled corticosteroid, a long-acting inhaled β₂-agonist (e.g., salmeterol, formoterol), a leukotriene modifier (i.e., montelukast, zafirlukast), or extended-release theophylline (with appropriate monitoring) may be added to low-dose inhaled corticosteroid therapy according to current asthma management guidelines; another preferred option is to increase the maintenance dosage of the inhaled corticosteroid to a medium dosage (e.g., exceeding 176 but not more than 352 mcg of fluticasone propionate [or its equivalent] daily via a metered-dose inhaler).106 In infants and children 4 years of age or younger with moderate persistent asthma that is not controlled by a low dosage of an inhaled corticosteroid, the only preferred option is to increase the maintenance dosage of the inhaled corticosteroid to a medium dosage (e.g., exceeding 176 but not more than 352 mcg of fluticasone propionate [or its equivalent] daily via a metered-dose inhaler).106

Severe Persistent Asthma

Maintenance therapy with an inhaled corticosteroid at medium or high dosages (e.g., exceeding 440 mcg of fluticasone propionate or its equivalent daily in adults and adolescents or 352 mcg of the drug in children 5-11 years of age or its equivalent via a metered-dose inhaler) and adjunctive therapy with a long-acting inhaled β₂-agonist is the preferred treatment according to current asthma management guidelines for adults and children 5 years of age or older with severe persistent asthma (i.e., continuous daytime asthma symptoms, nighttime symptoms 7 times per week).106,109 In infants and children 4 years of age or younger with severe asthma, maintenance therapy with an inhaled corticosteroid at medium or high dosages (e.g., exceeding 352 mcg of fluticasone propionate daily or its equivalent via a metered-dose inhaler) and adjunctive therapy with either a long-acting inhaled β₂-agonist or montelukast is recommended in current asthma management guidelines as the only preferred treatment.106

Poorly Controlled Asthma

If asthma symptoms in patients with moderate to severe asthma are very poorly controlled (i.e., at least 2-3 exacerbations per year requiring oral corticosteroids), a short course of an oral corticosteroid (3-10 days) may be added to gain prompt control of asthma.106 Regular use of oral corticosteroids as add-on therapy in adults and children 5 years of age or older with severe asthma who are inadequately controlled with high-dose inhaled corticosteroid, intermittent oral corticosteroid therapy, and a long-acting inhaled β₂-agonist bronchodilator is suggested, based on consensus and clinical experience.106,109 A short (2-week) course of oral corticosteroids may be considered to confirm clinical response prior to implementing long-term therapy with these agents.106 Once long-term oral corticosteroid therapy is initiated, the lowest possible effective dosage (i.e., alternate-day or once-daily administration) should be used, and the patient should be monitored carefully for adverse effects.106 Once asthma is well-controlled, repeated attempts should be made to reduce the oral corticosteroid dosage.106 Use of orally inhaled triamcinolone acetonide as adjunctive therapy in patients who require chronic administration of systemic corticosteroids to control asthma symptoms may permit a reduction in dosage or discontinuance of systemic corticosteroids.105 When used in recommended dosages in responsive patients, triamcinolone acetonide oral inhalation may permit control of asthmatic symptoms with less suppression of hypothalamic-pituitary-adrenal (HPA) function than therapeutically equivalent oral dosages of prednisone.105 For additional details on the stepped-care approach to drug therapy in asthma,100,101,103,106,109 see Asthma under Uses: Bronchospasm, in Albuterol 12:12.08.12 and see Asthma under Uses: Respiratory Diseases, in the Corticosteroids General Statement 68:04.

The route of administration and dosage of triamcinolone and its derivatives depend on the condition being treated and the response of the patient. IM therapy is generally reserved for patients who are not able to take the drug orally. Dosage for infants and children should be based on the severity of the disease and the response of the patient rather than on strict adherence to dosage indicated by age, body weight, or body surface area. After a satisfactory response is obtained, dosage should be decreased in small decrements to the lowest level that maintains an adequate clinical response, and the drug should be discontinued as soon as possible. Patients should be continually monitored for signs that indicate dosage adjustment is necessary, such as remissions or exacerbations of the disease and stress (surgery, infection, trauma). One manufacturer recommends that an alternate-day dosage regimen be considered when long-term oral triamcinolone therapy is necessary. However, most authorities state that only methylprednisolone, prednisolone, and prednisone have been proven to be suitable for alternate-day glucocorticoid therapy. Following long-term therapy, triamcinolone should be withdrawn gradually. (See Discontinuance of Therapy under Dosage and Administration: Dosage, in the Corticosteroids General Statement 68:04.)

Triamcinolone

Triamcinolone is administered orally. The initial adult dosage of triamcinolone may range from 4-48 mg daily depending on the disease being treated and is usually administered in 1-4 doses. Some clinicians state that children may be given a dosage of 0.117-1.66 mg/kg daily or 3.3-50 mg/m² daily, administered in 4 divided doses.

Triamcinolone Acetonide

Triamcinolone acetonide may be administered by IM, intra-articular, intrasynovial, intralesional (intradermal) or sublesional, and soft-tissue injection or by oral inhalation. Because it is slowly absorbed and its effects may persist for several weeks, IM administration of triamcinolone acetonide is not indicated when an immediate effect of short duration is required.

The usual IM dose for adults and children older than 12 years of age is 60 mg (using the 40-mg/mL sterile suspension). Additional IM doses of 20-100 mg (usually 40-80 mg) may be given when signs and symptoms recur. Some clinicians recommend that triamcinolone acetonide be administered IM at 6-week intervals, if possible, to minimize HPA suppression. Some clinicians state that children 6-12 years of age may receive 0.03-0.2 mg/kg or 1-6.25 mg/m² IM at 1- to 7-day intervals. IM dosage for children younger than 6 years of age has not been established, and triamcinolone acetonide should not be administered IM to children in this age group.

For intralesional (or sublesional) injections, the 10-mg/mL sterile suspension of triamcinolone acetonide is used. The usual intralesional or sublesional dose of triamcinolone acetonide is 1 mg per injection site and may be repeated 1 or more times a week depending on the response of the patient. A tuberculin syringe should be used to facilitate intralesional or sublesional dosage measurement. Multiple sites may be injected if they are at least 1 cm apart, but the total amount of triamcinolone acetonide administered intralesionally at any one time should not exceed 30 mg.

For intra-articular, intrasynovial, and soft-tissue injection, the usual dose of triamcinolone acetonide (using either the 10-mg/mL or 40-mg/mL sterile suspension) is 2.5-40 mg depending on the location of the affected area and the degree of inflammation; the dose may be repeated when signs and symptoms recur. Anti-inflammatory effects may be maintained for several weeks following intra-articular administration of the drug. A local anesthetic, such as procaine hydrochloride, may be infiltrated into the soft tissue surrounding the joint and/or injected into the joint before administration of triamcinolone acetonide. For large joints such as the knee, 15-40 mg of triamcinolone acetonide may be used. For smaller joints, 2.5-10 mg may be adequate. For soft-tissue injection in the treatment of tendon sheath inflammation, the usual dose is 2.5-10 mg.

For oral inhalation use, the triamcinolone acetonide oral aerosol inhaler delivers about 200 mcg of drug from the valve and 75 mcg from the spacer mouthpiece per metered spray under defined in vitro test conditions.105 The commercially available aerosol delivers at least 240 metered sprays; however, since reliable dosage delivery cannot be assured after 240 metered sprays, the aerosol inhaler should not be used after 240 actuations and patients should be cautioned against longer use of an individual inhaler.105 Patients should be carefully instructed in the use of the oral inhaler. To obtain optimum results, patients should also be given a copy of the patient instructions provided by the manufacturer. The inhaler should be shaken well immediately prior to use and inverted prior to actuation. After exhaling as completely as possible, the mouthpiece of the inhaler should be placed well into the mouth and the lips closed firmly around it. The patient should then inhale slowly and deeply through the mouth while pressing the metal canister down with the forefinger. After holding the breath for as long as possible (about 5-10 seconds), the mouthpiece should be removed and the patient should exhale slowly. If additional inhalations are required, the patient should wait 1 minute between inhalations, shake the inhaler again, and repeat the procedure. Following each treatment, the patient should rinse the mouth thoroughly with water or mouthwash to remove drug deposited in the oropharyngeal area.

Dosage of triamcinolone acetonide oral inhalation must be carefully adjusted according to individual requirements and response. The usual initial adult dosage by oral inhalation is 150 mcg (2 sprays) 3 or 4 times daily or 300 mcg (4 sprays) twice daily (450 or 600 mcg total).105 In adults with severe asthma, it may be advisable to start with 12-16 sprays daily (900-1200 mcg total), and then reduce the dosage to the lowest effective level.105 While the manufacturer states that a triamcinolone acetonide dosage of 1200 mcg (16 sprays) daily in adults should not be exceeded,105 some experts state that higher dosages may be used in adults with severe persistent asthma.100,102,106

In children 6-12 years of age, the usual initial dosage is 75 or 150 mcg (1 or 2 sprays) 3 or 4 times daily (225-600 mcg total) or 150 or 300 mcg (2-4 sprays) twice daily (300-600 mcg total); dosage is adjusted according to patient response.105 While the manufacturer states that dosage for children 6-12 years of age should not exceed 900 mcg (12 sprays) daily,105 some experts state that higher dosages may be used in children with severe persistent asthma.102,104,106 The manufacturer states that the drug is not recommended for use in children younger than 6 years of age.105 When orally inhaled triamcinolone acetonide is administered to patients receiving systemic corticosteroids, the patient's asthma should be reasonably stable before treatment with the oral inhalation begins.105 Initially, the aerosol is given concurrently with the maintenance dosage of the systemic corticosteroid. After about 1 week, the systemic corticosteroid is gradually withdrawn.105 (See Discontinuance of Therapy under Dosage and Administration: Dosage, in the Corticosteroids General Statement 68:04.) Gradual withdrawal of systemic corticosteroids following long-term therapy is strongly recommended, since death has occurred in some individuals in whom systemic corticosteroids were withdrawn too rapidly . 105 After systemic corticosteroids have been withdrawn, if exacerbations of asthma occur during triamcinolone acetonide oral inhalation therapy, short courses of systemic corticosteroids should be given, then tapered as symptoms subside.105

Triamcinolone Hexacetonide

Triamcinolone hexacetonide may be administered by intra-articular, intralesional, or sublesional injection. Sterile suspensions of triamcinolone hexacetonide may be diluted with a local anesthetic such as 1% or 2% lidocaine hydrochloride prior to intra-articular or intralesional injection or with sterile water for injection, 0.9% sodium chloride injection, or 5% or 10% dextrose in 0.9% sodium chloride injection prior to intralesional administration. Diluents containing preservatives such as parabens or phenols should be avoided. (See Chemistry and Stability: Stability.) For intralesional (or sublesional) injection, the 5-mg/mL sterile suspension of triamcinolone hexacetonide is used.

The usual dosage for intralesional (or sublesional) injection is up to 0.5 mg per square inch of affected skin. Additional injections should be administered according to the response of the patient. For intra-articular injections, the usual dosage of triamcinolone hexacetonide (using the 20-mg/mL sterile suspension) is 2-20 mg depending on the size of the joint, degree of inflammation and amount of fluid present; doses may be repeated at intervals of 3-4 weeks. For large joints such as the knee, 10-20 mg may be used. For smaller joints such as in the fingers, 2-6 mg may be adequate.

Chemistry and Stability

Chemistry

Triamcinolone is a synthetic glucocorticoid. The free alcohol occurs as a white or practically white, odorless, crystalline powder and is very slightly soluble in water and slightly soluble in alcohol. Triamcinolone acetonide occurs as a white to cream-colored, crystalline powder having not more than a slight odor and is practically insoluble in water and very soluble in dehydrated alcohol. The diacetate ester of triamcinolone occurs as a white to off-white, fine crystalline powder with not more than a slight odor and is practically insoluble in water and sparingly soluble in alcohol. Triamcinolone hexacetonide occurs as a white to cream-colored powder and is practically insoluble in water and very slightly soluble in alcohol.

Commercially available sterile suspensions of triamcinolone acetonide and triamcinolone hexacetonide have a pH of 5-7.5 and 4-8, respectively.

For oral inhalation, triamcinolone acetonide is commercially available as an aerosol containing a microcrystalline suspension of the drug in a vehicle of a fluorocarbon propellant (dichlorodifluoromethane) and dehydrated alcohol. Although triamcinolone acetonide is administered by an oral inhaler that produces metered sprays containing 200 mcg of triamcinolone acetonide per spray, each actuation of the inhaler delivers a dose equivalent to 100 mcg of triamcinolone acetonide, since a portion of each spray is retained within the delivery device.

Stability

Commercially available oral and parenteral preparations of triamcinolone should be stored at a temperature less than 40 °C, preferably between 15-30 °C; freezing of the sterile suspensions should be avoided. Exposure of sterile suspensions of the drug to freezing temperatures can result in irreversible clumping or agglomeration (granular appearance); such suspensions should not be used. Triamcinolone tablets should be stored in well-closed containers. Triamcinolone acetonide sterile suspension should be protected from light. Triamcinolone acetonide oral inhaler should be stored at controlled room temperature (20-25 °C).105 Because the contents of the oral inhaler are under pressure, the aerosol container should not be punctured, used or stored near heat or an open flame, exposed to temperatures exceeding 49 °C, or placed into a fire or incinerator for disposal.105

Sterile suspensions of triamcinolone hexacetonide should not be mixed with diluents or local anesthetics containing preservatives (such as parabens or phenols) because flocculation of the suspension may result. Unused diluted suspensions of the hexacetonide esters of triamcinolone should be discarded after 7 days.

Additional Information

For further information on chemistry, pharmacology, pharmacokinetics, uses, cautions, drug interactions, laboratory test interferences, and dosage and administration of triamcinolone, see the Corticosteroids General Statement 68:04. For EENT and topical uses, see 52:08.08 and 84:06.08, respectively. The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer's labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.

Only references cited for selected revisions after 1984 are available electronically.

100. National Asthma Education and Prevention Program. Expert panel report II: guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health; 1997 Feb.

101. National Asthma Education Program. Executive summary: guidelines for the diagnosis and management of asthma. NIH Publication. No. 94-3042A. Washington, DC: US Governement Printing Office; 1994 Jul.

102. National Institutes of Health, National Heart, Lung, and Blood Institute. Global initiative for asthma: global strategy for asthma management and prevention NHLBI/WHO Workshop Report. Bethesda, MD: National Institutes of Health. 2007 Dec 19. NIH/NHLBI Publication No. 02-3659. Available at NIH website. Accessed Jul 27, 2008. [Web]

103. British Thoracic Society. Guidelines on the management of asthma. Thorax . 1993; 48(Suppl 2):S1-24.

104. National Asthma Education and Prevention Program. Expert panel report: guidelines for the diagnosis and management of asthma update on selected topics—2002. J Allergy Clin Immunol . 2002; 110(Suppl.5):S141-219.

105. Abbott Laboratories. Azmacort^® (triamcinolone acetonide) inhalation aerosol prescribing information. Bridgewater, PA; 2007 Sep.

106. National Asthma Education and Prevention Program. Expert panel report III: guidelines for the diagnosis and management of asthma. 2007 Jul. Bethesda, MD: U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute. Available at NIH website. Accessed Jul 27, 2008. [Web]

107. Abbott Laboratories. Azmacort^® (triamcinolone acetonide) inhalation aerosol. Available from: [Web]/. Accessed 2010 Oct 25.

108. Food and Drug Administration. Asthma and COPD inhalers that contain ozone-depleting CFCs to be phased out; alternative treatments available. 2010 Apr 13. Available from: [Web]. Accessed 2010 Oct 14.

109. National Institutes of Health, National Heart, Lung, and Blood Institute. Global initiative for asthma: global strategy for asthma management and prevention. Bethesda, MD: National Institutes of Health. 2009 Dec. Available from: [Web]. Accessed 2010 Sep 23. [Web]

1000. Food and Drug Administration. Epidural corticosteroid injection: Drug safety communication - risk of rare but serious neurologic problems. 2014 Apr 23. From FDA website. Accessed 2014 May 19. [Web]

1001. Food and Drug Administration. FDA drug safety communication: FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain. 2014 Apr 23. From FDA website. Accessed 2014 May 19. [Web]

1002. Rathmell JP. Toward improving the safety of transforaminal injection. Anesth Analg . 2009; 109:8-10. [PubMed 19535690]

1003. Cohen SP, Bicket MC, Jamison D et al. Epidural steroids: a comprehensive, evidence-based review. Reg Anesth Pain Med . 2013 May-Jun; 38:175-200.