triamcinolone (systemic)

In pharmacologic doses, suppresses inflammation and the normal immune response.
Has numerous intense metabolic effects (see Adverse Reactions and Side Effects).
Suppresses adrenal function at chronic doses of 4 mg/day.
Has negligible mineralocorticoid activity.

Therapeutic effects:

Suppression of inflammation and modification of the normal immune response.
Replacement therapy in adrenal insufficiency.

Pharmacokinetics ⬆ ⬇

Absorption: Well absorbed following oral administration. Acetonide salt is slowly but completely absorbed following IM administration. Absorption of acetonide salt from local sites (intra-articular, intralesional) is slow but complete.

Distribution: Widely distributed.

Metabolism/Excretion: Metabolized mostly by the liver.

Half-Life: 2–>5 hr (plasma), 18–36 hr (tissue).

Time/Action Profile ⬆ ⬇

(anti-inflammatory activity)

ROUTE	ONSET	PEAK	DURATION
IM (acetonide)	24–48 hr	unknown	1–6 wk

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Active untreated infections (may be used in patients being treated for tuberculous meningitis);
Epidural use (may result in serious neurological injury or death);
Some products contain tartrazine; avoid in patients with known hypersensitivity;
Pedi: Avoid use of products containing benzyl alcohol in neonates.

Use Cautiously in:

Chronic treatment (will lead to adrenal suppression; use lowest possible dose for shortest time);
Hypothyroidism;
Cirrhosis;
Ulcerative colitis;
Stress (surgery, infections); supplemental doses may be needed;
Potential infections may mask signs (fever, inflammation);
Traumatic brain injury (high doses may be associated with ↑ mortality);
OB: Safety not established in pregnancy;
Lactation: Safety not established in breastfeeding;
Pedi: Chronic use will result in growth in children; use lowest possible dose for shortest time.

Adv. Reactions/Side Effects ⬆ ⬇

Adverse reactions/side effects are much more common with high-dose/long-term therapy

CV: hypertension, edema (long-term high doses)

Derm: acne, ↓wound healing, ecchymoses, fragility, hirsutism, petechiae

EENT: cataracts, ↑intraocular pressure

Endo: adrenal suppression, hyperglycemia

F and E: hypokalemia, hypokalemic alkalosis

GI: anorexia, nausea, PEPTIC ULCERATION, vomiting

Hemat: THROMBOEMBOLISM

Local: thrombophlebitis

Metab: weight gain, weight loss

MS: muscle wasting, osteoporosis, avascular necrosis of joints, muscle pain

Neuro: depression, euphoria, headache, ↑intracranial pressure (children only), personality changes, psychoses, restlessness

Misc: cushingoid appearance (moon face, buffalo hump), HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS AND ANGIOEDEMA), INFECTION, KAPOSI'S SARCOMA

Interactions ⬆ ⬇

Drug-drug:

Additive hypokalemia with thiazide and loop diuretics, or amphotericin B.
Hypokalemia may ↑ risk of digoxin toxicity.
May ↑ requirement for insulin or oral hypoglycemic agents.
Phenytoin, phenobarbital, and rifampin stimulate metabolism; may ↓ effectiveness.
Oral contraceptives may ↓ metabolism.
↑risk of adverse GI effects with NSAIDs (including aspirin).
At chronic doses that suppress adrenal function, may ↓ the antibody response to and ↑ the risk of adverse reactions from live-virus vaccines.

Route/Dosage ⬆ ⬇

IM (Adults ): Triamcinolone acetonide: 40–80 mg every 4 wk.
Intra-articular
(Adults ): Triamcinolone acetonide (Zilretta): 32 mg as a single dose into the knee joint
IM (Children ): Triamcinolone acetonide: 40 mg every 4 wk or 30–200 mcg/kg (1–6.25 mg/m²) every 1–7 days.

Availability ⬆ ⬇

(Generic available)

Extended-release suspension for intra-articular injection (acetonide) (Zilretta): 32 mg/vial
Suspension for intramuscular injection (acetonide): 10 mg/mL; 40 mg/mL; 80 mg/mL

Assessment ⬆ ⬇

This drug is indicated for many conditions. Assess involved systems before and periodically during therapy.
Monitor for signs and symptoms of adrenal insufficiency (fatigue, weakness, nausea and vomiting, low BP); drug should be tapered more slowly.
Monitor for signs and symptoms of hypercorticism (moon face, buffalo hump, stretch marks, obesity, bruising, hyperglycemia, elevated BP) every 6 mo; pediatric patients <1 yr of age may require more frequent monitoring (every 3 to 4 mo); temporary discontinuation, dose ↓, or slowed taper.
Assess for signs and symptoms of infection (fever, chills, sore throat, wound that will not heal).
Assess for signs and symptoms of Kaposi's sarcoma (purple, red, or brown skin blotches on skin or inside the mouth) with long-term use.
Monitor intake and output ratios and daily weights. Observe for peripheral edema, steady weight gain, rales/crackles, or dyspnea. Notify health care professional should these occur.
Evaluate growth of children periodically during therapy. Monitor linear growth and weight gain. Adjust doses accordingly.

Lab Test Considerations:

Monitor CBC, serum electrolytes, serum and urine glucose, and lipid panel routinely during therapy. May cause hyperglycemia, especially in patients with diabetes. May cause hypokalemia, hypocalcemia, and hypernatremia. May ↓ WBC counts. May ↑ lipid values.
- May suppress reactions to allergy skin tests.
- May ↓ uptake of thyroid ¹²³I or ¹³¹I.
- Guaiac test stools. Promptly report presence of guaiac-positive stools.
- Periodic adrenal function tests may be ordered to assess degree of hypothalamic-pituitary-adrenal axis suppression in systemic and chronic topical therapy.

Implementation ⬆ ⬇

Zilretta is not interchangeable with other forms of injectable triamcinolone and should be administered via intra-articular route only.
IM: Shake suspension well before drawing up. IM doses should not be administered when rapid effect is desirable. Do not dilute with other solution or admix. Do not administer suspensions IV.
Intra-articular: Inject promptly after preparation.For Zilretta,dilute using diluent supplied in kit. Follow manufacturer's instructions. Some residue may be left behind on vial walls after withdrawing the contents. Gently swirl vial to resuspend any of the settled microspheres before preparing syringe for injection. Stable for 4 hr at room temperature. Do not administer Zilretta via epidural, intrathecal, IV, intraocular, IM, intradermal, or SUBQ routes.

Patient/Family Teaching ⬆ ⬇

Explain purpose and side effects of triamcinolone to patient. Do not stop receiving drug without consulting health care professional. If an appointment is missed, contact health care professional as soon as possible to reschedule. Advise patient to read Medication Guidebefore starting and periodically during therapy in case of changes.
- Explain need for continued medical follow-up to assess effectiveness and possible side effects of medication. Periodic lab tests and eye exams may be needed.
- Stopping the medication suddenly may result in adrenal insufficiency (anorexia, nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia). If these signs appear, notify health care professional immediately. This can be life-threatening. Medical ID should be worn in case of emergencies
- Corticosteroids cause immunosuppression and may mask symptoms of infection. May worsen existing tuberculosis; fungal, bacterial, viral, or parasitic infections; or ocular herpes simplex. Instruct patient to notify health care professional immediately if exposed to chicken pox or measles.
- Caution patient to avoid vaccinations without first consulting health care professional.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking other medications.
- Instruct patient to notify health care professional if pregnancy is planned or suspected or if breastfeeding. Hypoadrenalism may occur in infants born to mothers receiving corticosteroids during pregnancy. Observe infant for signs of hypoadrenalism (poor feeding, irritability, weakness, vomiting).
Long-term Therapy: Encourage patient to eat a diet high in protein, calcium, and potassium and low in sodium and carbohydrates (see Ophthalmic Medications). Alcohol should be avoided during therapy.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇