Triamcinolone is a corticosteroid medication used to treat a variety of conditions, including inflammation, allergic reactions, and autoimmune disorders. It works by reducing inflammation and suppressing the immune system's response. Triamcinolone can be administered orally, topically (as a cream, ointment, or lotion), by injection into a joint or muscle, or by injection into the affected area for localized treatment.

Triamcinolone (Kenalog) is a long-acting corticosteroid that has minimal salt-retaining properties. It suppresses inflammation and is used in the treatment of various autoimmune rheumatic and inflammatory conditions.

Triamcinolone Uses:

• Intra-articular or soft tissue administration (triamcinolone hexacetonide [Canadian product]):
  • Indicative treatment of subacute and persistent inflammatory joint diseases comprising:
    • synovitis, tendinitis, bursitis, epicondylitis, rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), osteoarthritis, or post-traumatic arthritis.
• Intralesional administration (triamcinolone acetonide [Kenalog-10 only]):
  • Alopecia areata;
  • discoid lupus erythematosus;
  • keloids;
  • contained hypertrophic,
  • penetrated,
  • inflammatory abrasions of granuloma annulare,
  • lichen planus,
  • lichen simplex chronicus (neurodermatitis),
  • psoriatic plaques;
  • necrobiosis lipoidica diabeticorum;
  • cystic tumors of an aponeurosis or ligament (ganglia).
• Intramuscular administration (triamcinolone acetonide [Kenalog-40] only):
  • Allergic states:
    • Management of acute or debilitating allergic conditions difficult to sufficient trials of standard 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
    • acute erythema multiforme (Stevens-Johnson syndrome).
  • Endocrine disorders:
    • Primary or secondary adrenocortical deficiency (hydrocortisone or cortisone is the drug of choice),
    • genetic adrenal hyperplasia,
    • hypercalcemia linked with cancer, or
    • nonsuppurative thyroiditis.
  • GI diseases:
    • To surge the patient over a vital period of the disease in Crohn's disease or ulcerative colitis.
  • Hematologic disorders:
    • Obtained (autoimmune) hemolytic anemia,
    • Diamond-Blackfan anemia,
    • sheer red cell aplasia,
    • limited cases of secondary thrombocytopenia.
  • Neoplastic diseases:
    • Placebo management of leukemia and lymphomas.
  • Nervous system:
    • Severe aggravations of multiple sclerosis;
    • cerebral edema associated with a primary or metastatic brain tumor or craniotomy.
    • Note: Treatment standards propose the use of high-dose IV or oral methylprednisolone for acute exacerbations of multiple sclerosis.
  • Ophthalmic diseases:
    • Sympathetic ophthalmia,
    • temporal arteritis,
    • uveitis, and
    • ocular inflammatory conditions unresponsive to relevant corticosteroids.
  • Renal diseases:
    • To provoke diuresis or diminution of proteinuria in idiopathic nephrotic syndrome or that is caused by lupus erythematosus.
  • Respiratory diseases:
    • Berylliosis,
    • fulminating or disseminated pulmonary tuberculosis when used simultaneously with suitable antituberculosis chemotherapy,
    • idiopathic eosinophilic pneumonia,
    • symptomatic sarcoidosis.
  • Rheumatic disorders:
    • As adjunctive treatment for brief administration in serious 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 participation;
    • tuberculous meningitis with subarachnoid block or imminent block when used with appropriate antituberculosis chemotherapy.

Read:

• Prednisone
• Solumedrol (methylprednisolone)
• Hydrocortisone

Triamcinolone (Kenalog) Dose in Adults 

Triamcinolone (Kenalog) Dose in the treatment of Dermatoses (steroid-responsive):

• In treating dermatoses (conditions affecting the skin) that respond to steroids, like eczema or psoriasis, Triamcinolone acetonide, often sold as Kenalog-10, is used.
• The typical dose for injection directly into the affected area is 1 milligram.
• The initial dose depends on the particular disease and the lesion being treated.
• It may be necessary to repeat the injection weekly or less frequently.
• If there are multiple affected areas, injections can be given as long as they are at least 1 centimeter apart.

Triamcinolone (Kenalog) Gout, acute flares (alternative agent):

• In the treatment of acute flares of gout, especially when oral medications can't be taken or when limited to 1 to 2 joints, Triamcinolone acetonide, commonly known as Kenalog-10, is used.
• For larger joints like the knee, a dose of 40 mg is typical, while medium joints such as the wrist or ankle may receive 30 mg, and smaller joints about 10 mg.
• If the flare involves multiple joints and intra-articular injection isn't feasible, an intramuscular injection of Kenalog-40 is an option, typically given at an initial dose of 40 to 60 mg as a single injection, which can be repeated once or twice at intervals of at least 48 hours if needed.
• However, caution should be exercised not to use triamcinolone if there is a suspicion of infection in the affected area.

Triamcinolone (Kenalog) Dose in the treatment of Inflammatory/allergic conditions/other steroid-responsive systemic conditions:

• In the treatment of various inflammatory, allergic, or systemic conditions that respond to steroids, such as severe allergies or certain autoimmune diseases, Triamcinolone acetonide, commonly known as Kenalog-40, can be administered intramuscularly.
• The typical initial dose is 60 mg, but it can be adjusted within a range of 40 to 80 mg depending on the patient's response and the severity of the condition.
• For patients with hay fever or pollen-induced asthma who haven't responded to other treatments, a single injection of 40 mg to 100 mg per season may be given.

Triamcinolone (Kenalog) Dose in the treatment of Multiple sclerosis (acute exacerbation):

• In the treatment of acute exacerbations of multiple sclerosis, high-dose intravenous or oral methylprednisolone is recommended by treatment guidelines.
• However, if Triamcinolone acetonide, also known as Kenalog-40, is used, the typical regimen involves an intramuscular injection of 160 mg daily for one week, followed by 64 mg every other day for one month.
• It's important to note that while this regimen may be an alternative, it's not the first-line treatment according to current guidelines.

Triamcinolone (Kenalog) Dose in the treatment of Rheumatic conditions (excluding acute gout flares):

• In the treatment of rheumatic conditions, excluding acute gout flares, Triamcinolone acetonide, commonly known as Kenalog-40, can be administered intra-articularly (directly into the joint), intrabursally (around a joint), or into tendon sheaths.
• The initial dose varies based on joint size, with smaller joints typically receiving 2.5 to 5 mg and larger joints receiving 5 to 15 mg, though doses may be adjusted up to 10 mg for small joints and up to 40 mg for large joints, with a maximum total dose of 80 mg per treatment session for several joints.
• If using Kenalog-40 intramuscularly, the initial dose is typically 60 mg, with a range of 2.5 to 100 mg per day.
• Additionally, there are specific dosing regimens for other formulations like Zilretta and Hexacetonide.

Triamcinolone (Kenalog) Dose in Children

Adjust dose varying upon the condition being treated and the reaction of the patient. The lowest possible dose must be used to regulate the condition; when dose reduction is possible, the dose should be reduced slowly.

Note: Aristospan Intra-Articular and Aristospan Intralesional have been suspended in the US for more than 1 year.

Triamcinolone (Kenalog) General dosing, treatment of inflammatory and allergic conditions:

• For the treatment of inflammatory and allergic conditions in children and adolescents, the general dosing of Triamcinolone, specifically Kenalog-40, can vary based on the formulation and the age of the patient:
• According to the manufacturer's labeling, the typical initial dose is 0.11 to 1.6 mg per kilogram of body weight per day (or 3.2 to 48 mg per square meter of body surface area per day) administered intramuscularly in 3 to 4 divided doses.
• In the absence of extensive data, alternate dosing regimens suggest a range of 0.03 to 0.2 mg per kilogram of body weight per dose for children aged 6 to 12 years, given intramuscularly every 1 to 7 days.

Triamcinolone (Kenalog) Dose in the treatment of Juvenile idiopathic arthritis (JIA), and other rheumatic conditions:

For the treatment of juvenile idiopathic arthritis (JIA) and other rheumatic conditions in children and adolescents, Triamcinolone can be administered intra-articularly (directly into the joint).

According to the manufacturer's labeling:

• Triamcinolone acetonide (Kenalog-10 or Kenalog-40):
  • Initial dose:
    • Smaller joints: 2.5 to 5 mg
    • Larger joints: 5 to 15 mg
  • Maximum dose per treatment session (for multiple joints): 20 to 80 mg
• Triamcinolone hexacetonide (Aristospan 20 mg/ml):
  • 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: Every 3 to 4 weeks as necessary, aiming to use as infrequently as possible to avoid potential joint damage.

Alternate dosing guidelines, based on limited data, suggest:

• Triamcinolone hexacetonide:
  • Intra-articular injection into large joints (typically knees, ankles): 1 to 1.5 mg per kilogram of body weight per dose, with a maximum dose of 40 mg.
  • Doses greater than 1.5 mg per kilogram have not shown additional clinical benefit. Similar dosing for triamcinolone acetonide can be used, but data suggests a greater and longer-lasting response with hexacetonide.

Triamcinolone (Kenalog) Dose in the treatment of severe Infantile hemangioma:

• Infants and Children up to 49 months of age:
  • Intralesional injection: The dosage is dependent on the size of the lesion.
  • Commonly reported dosages:
    • 1 to 2 mg per kilogram of body weight per dose of the triamcinolone acetonide suspension, either in 10 mg/mL or 40 mg/mL concentration, administered in divided doses along the perimeter of the lesion approximately monthly.
    • Maximum dose: Up to 30 mg per dose has been used.
    • Another reported dosage regimen: 1 to 30 mg of the 10 mg/mL acetonide injection divided into multiple injections along the lesion.
  • Combination therapy: Triamcinolone has also been used in combination with betamethasone intralesional injections.

From reported experiences:

• A large study (n=1514, age range: 1 to 49 months) showed that triamcinolone (1 to 2 mg/kg once every month) alone or in combination with oral corticosteroids resulted in a decrease in lesion size of 50% or more in 90.3% of infants (age <1 year) and 80% in those >1 year.
• Another trial (n=155, age range at first injection: 2 to 12 months) used 1 to 30 mg of a 10 mg/mL concentration administered approximately once monthly for 3 to 6 months, resulting in a decrease in lesion size by at least 50% in 85% of patients.

Triamcinolone (Kenalog) Dose in the treatment of steroid-responsive dermatoses (including contact and atopic dermatitis): 

Triamcinolone acetonide (Kenalog-10):

• Intradermal injection:
  • Adolescents: Up to 1 mg per injection site, which may be repeated one or more times weekly.
  • Multiple sites may be injected if they are at least 1 cm apart.
  • Maximum total dose: Not to exceed 30 mg.

Triamcinolone hexacetonide (Aristospan 5 mg/mL):

• Intralesional or sublesional injection:
  • Adolescents: Up to 0.5 mg per square inch of affected skin.
  • Initial dosage range: 2 to 48 mg.
  • Frequency of dose is determined by clinical response.

These dosing regimens should be adjusted based on individual patient factors, the severity of the dermatosis, and the response to treatment.

Triamcinolone (Kenalog) Pregnancy Risk Category: C

• Corticosteroids, like triamcinolone, have been linked to adverse effects in animal studies during pregnancy.
• Some studies suggest a connection between using corticosteroids in the first trimester of pregnancy and issues like oral clefts or lower birth weight in babies, but the data is mixed and can depend on factors like the mother's dosage and why she's taking them.
• Newborns of mothers who used corticosteroids during pregnancy might have low adrenal function, so monitoring is important.
• When corticosteroids are necessary during pregnancy for conditions like rheumatic disorders, it's usually advised to use the smallest amount for the shortest time, especially avoiding high doses in the first trimester.
• For skin problems during pregnancy, oral corticosteroids are generally not the first choice and should be avoided in the first trimester, but they might be used in the second or third trimesters at the lowest effective dose.

Triamcinolone use during breastfeeding:

• Corticosteroids, like triamcinolone, can pass into breast milk, potentially causing issues for the breastfeeding baby such as slowed growth or affecting their own corticosteroid production.
• Therefore, caution is advised when corticosteroids are given to breastfeeding mothers.
• A case study showed a decrease in milk supply in a mother who received a high-dose triamcinolone injection while breastfeeding.
• Generally, corticosteroids are considered safe for breastfeeding when used in typical doses, but monitoring the baby's health is recommended.
• Some guidelines suggest waiting four hours after taking an oral corticosteroid before breastfeeding to reduce the baby's exposure to the medication, based on studies with prednisolone.

Dose in Kidney Disease:

• The manufacturer's labeling for triamcinolone does not specify dosage adjustments for individuals with renal impairment.

• However, caution should be exercised when using the medication in this population.

Dose in Liver disease:

• The manufacturer's labeling for triamcinolone does not include specific dosage adjustments for individuals with hepatic impairment.
• However, caution should be exercised when administering the medication to patients with liver issues.

Side Effects of Triamcinolone (Kenalog):

• Hematologic & oncologic:
  • Bruise
• Neuromuscular & skeletal:
  • Joint swelling
• Respiratory:
  • Cough
  • Sinusitis

Less common side effects of Triamcinolone (Kenalog):

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
  • Idiopathic Intracranial Hypertension (Upon Discontinuation)
  • Increased Intracranial Pressure
  • Insomnia
  • Malaise
  • Meningitis
  • Mood Changes
  • Myasthenia
  • Neuritis
  • Neuropathy
  • Paraplegia
  • Paresthesia
  • Personality Changes
  • Psychiatric Disturbance
  • Quadriplegia
  • Seizure
  • Spinal Cord Infarction
  • Vertigo
• Dermatologic:
  • Acne Vulgaris
  • Allergic Dermatitis
  • Atrophic Striae
  • Diaphoresis
  • Ecchymoses
  • Epidermal Thinning
  • Erythema Of Skin
  • Exfoliation Of Skin
  • Hyperpigmentation
  • Hypertrichosis
  • Hypopigmentation
  • Inadvertent Suppression Of Skin Test Reaction
  • Skin Atrophy
  • Skin Rash
  • Subcutaneous Atrophy
  • Thinning Hair
  • Urticaria
  • Xeroderma
• Endocrine & Metabolic:
  • Calcinosis
  • Decreased Glucose Tolerance
  • Decreased Serum Potassium
  • Diabetes Mellitus
  • Drug-Induced Cushing's Syndrome
  • Fluid Retention
  • Glycosuria
  • Growth Retardation
  • 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
  • Petechia
• 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

   Contraindications to Triamcinolone (Kenalog):

• Triamcinolone should not be used if there is a known hypersensitivity to triamcinolone itself or any components of the formulation.
• For Triamcinolone hexacetonide, additional contraindications include acute psychoses, active tuberculosis, herpes simplex keratitis, systemic mycoses, parasitic infections like strongyloides, and children under 3 years of age due to the presence of benzyl alcohol.
• In cases of immune thrombocytopenia, triamcinolone should only be administered via intramuscular injection.
• Although documentation of allergenic cross-reactivity for corticosteroids is limited, caution should be exercised due to potential similarities in chemical structure or pharmacologic actions that might lead to cross-sensitivity reactions.

Warnings and precautions

Suppression of the adrenals:

• Triamcinolone can lead to adrenal suppression, especially in younger children or with long-term, high-dose use, potentially causing hypercortisolism or suppression of the hypothalamic-pituitary adrenal (HPA) axis.
• This suppression may result in adrenal crisis.
• It's crucial to withdraw or discontinue corticosteroids slowly and carefully to mitigate these risks.
• When transitioning patients from systemic corticosteroids to inhaled products, extra caution is necessary due to the potential for adrenal insufficiency or withdrawal symptoms, including worsened allergic reactions.
• Patients receiving high doses, especially over 20 mg per day of prednisone or its equivalent, are most susceptible.
• Fatalities have occurred in asthmatic patients during and after the switch from systemic to aerosol steroids because aerosol steroids don't provide the systemic steroid support needed in situations like trauma, surgery, or infections.

Anaphylactoid reactions

• Rare instances of anaphylactoid reactions have been noted in patients receiving corticosteroids, including triamcinolone.
• In some cases, serious anaphylaxis, including fatalities, have been reported with the use of triamcinolone acetonide.

Dermal changes:

• Triamcinolone use can lead to dermal changes, including skin thinning (atrophy) at the injection site.
• It's advised to avoid intramuscular injections into the deltoid muscle to prevent potential subcutaneous atrophy.

Immunosuppression:

• Prolonged use of corticosteroids like triamcinolone can suppress the immune system, increasing the risk of secondary infections and activating latent ones.
• It may also mask signs of acute infections, including fungal ones, prolong or worsen viral infections, or weaken the body's response to vaccines.
• Patients should avoid contact with individuals infected with chickenpox or measles.
• Corticosteroids should not be used to treat certain conditions like ocular herpes simplex, cerebral malaria, fungal infections, or viral hepatitis.
• Close monitoring is needed in patients with latent tuberculosis or TB reactivity, and corticosteroids should be used cautiously in active tuberculosis cases.
• Patients with recent travel to tropical areas or unexplained diarrhea should be tested for amebiasis before starting corticosteroids.
• Extreme caution is warranted in patients with Strongyloides infections, as there's a risk of hyperinfection, dissemination, and even death.

Kaposi Sarcoma:

• Prolonged use of corticosteroids like triamcinolone has been linked to the development of Kaposi sarcoma, as reported in case studies.
• If Kaposi sarcoma is observed in patients receiving corticosteroid treatment, discontinuation of therapy should be considered.

Myopathy

• Acute myopathy, a muscle disorder, has been reported with high doses of corticosteroids, particularly in patients with neuromuscular transmission disorders or when given alongside neuromuscular blocking agents.
• This condition may affect muscles involved in vision or breathing.

Psychiatric disorders:

• The use of corticosteroids, including triamcinolone, can lead to psychiatric disturbances ranging from mild symptoms like euphoria, insomnia, mood swings, and personality changes to more severe manifestations like depression and psychotic symptoms.
• Existing psychiatric conditions may also worsen with corticosteroid use.

Septic arthritis:

• Septic arthritis, an infection in the joint, can potentially occur as a complication of intra-articular or soft tissue administration of corticosteroids like triamcinolone.
• If septic arthritis is suspected or confirmed, it's crucial to promptly initiate appropriate antimicrobial therapy to treat the infection.

Cardiovascular disease

• In patients with heart failure (HF) and/or hypertension, caution is advised when using corticosteroids like triamcinolone due to potential complications.
• Corticosteroid use has been linked to fluid retention, electrolyte imbalances, and elevated blood pressure.
• Additionally, in individuals recovering from an acute myocardial infarction (MI), corticosteroids should be used cautiously as they have been associated with an increased risk of myocardial rupture.

Diabetes:

• Patients with diabetes mellitus should use corticosteroids like triamcinolone with caution, as these medications can affect glucose production and regulation in the body, potentially leading to elevated blood sugar levels (hyperglycemia).

Gastrointestinal Disease:

• Corticosteroids like triamcinolone should be used cautiously or avoided in patients with gastrointestinal (GI) diseases such as diverticulosis, diverticulitis, fresh intestinal anastomoses, active or latent peptic ulcers, ulcerative colitis, or abscesses, as they may increase the risk of GI perforation.

Head injury

• High-dose corticosteroids, including IV methylprednisolone, should not be used for the management of head injury.
• Studies have shown an increased risk of mortality in patients receiving high doses of IV methylprednisolone for head injuries.

Hepatic impairment

• Patients with hepatic impairment, including cirrhosis, should use corticosteroids like triamcinolone with caution.
• Long-term use of corticosteroids has been associated with fluid retention, which can exacerbate complications in patients with hepatic impairment.

Myasthenia gravis:

• Patients with myasthenia gravis should use corticosteroids like triamcinolone with caution due to the potential for exacerbation of symptoms, particularly during initial treatment.
• Corticosteroids can sometimes worsen muscle weakness in patients with myasthenia gravis.

Ocular disease:

• In patients with ocular disease, including cataracts and glaucoma, corticosteroids like triamcinolone should be used cautiously.
• Prolonged use of corticosteroids has been associated with increased intraocular pressure, open-angle glaucoma, and cataract formation.
• Additionally, in patients with a history of ocular herpes simplex, caution is warranted as corticosteroid use may lead to corneal perforation, and they should not be used during active ocular herpes simplex infections.
• Corticosteroids are not recommended for the treatment of optic neuritis, as they may increase the frequency of new episodes.

Osteoporosis

• Patients with osteoporosis should use corticosteroids like triamcinolone with caution, as high doses or long-term use of corticosteroids have been linked to increased bone loss and an elevated risk of osteoporotic fractures.

Renal impairment

• Patients with renal impairment should use corticosteroids like triamcinolone with caution, as these medications may lead to fluid retention, exacerbating renal issues.

Seizure disorders:

• Patients with a history of seizure disorder should use corticosteroids like triamcinolone with caution, as seizures have been reported in the context of adrenal crisis.

Thyroid disease:

• Patients with thyroid disease may require dosage adjustments when using corticosteroids like triamcinolone.
• Changes in thyroid status can affect the metabolic clearance of corticosteroids: in hyperthyroid patients, the clearance increases, while in hypothyroid patients, it decreases.

Triamcinolone (systemic): Drug Interaction

Risk Factor C (Monitor therapy)
Acetylcholinesterase Inhibitors	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Acetylcholinesterase Inhibitors. Increased muscular weakness may occur.
Amphotericin B	Corticosteroids (Systemic) may enhance the hypokalemic effect of Amphotericin B.
Amphotericin B	Corticosteroids (Orally Inhaled) may enhance the hypokalemic effect of Amphotericin B.
Androgens	Corticosteroids (Systemic) may enhance the fluid-retaining effect of Androgens.
Antidiabetic Agents	Hyperglycemia-Associated Agents may diminish the therapeutic effect of Antidiabetic Agents.
Antihepaciviral Combination Products	May increase the serum concentration of Triamcinolone (Systemic).
Calcitriol (Systemic)	Corticosteroids (Systemic) may diminish the therapeutic effect of Calcitriol (Systemic).
Coccidioides immitis Skin Test	Immunosuppressants may diminish the diagnostic effect of Coccidioides immitis Skin Test.
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.
Cosyntropin	Corticosteroids (Orally Inhaled) may diminish the diagnostic effect of Cosyntropin.
Cosyntropin	Corticosteroids (Systemic) may diminish the diagnostic effect of Cosyntropin.
CYP3A4 Inducers (Strong)	May decrease the serum concentration of Corticosteroids (Systemic).
CYP3A4 Inhibitors (Strong)	May increase the serum concentration of Corticosteroids (Systemic).
Deferasirox	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased.
Deferasirox	Corticosteroids may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased.
Denosumab	May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased.
DilTIAZem	May increase the serum concentration of Corticosteroids (Systemic).
Estrogen Derivatives	May increase the serum concentration of Corticosteroids (Systemic).
Indacaterol	May enhance the hypokalemic effect of Corticosteroids (Systemic).
Isoniazid	Corticosteroids (Systemic) may decrease the serum concentration of Isoniazid.
Loop Diuretics	Corticosteroids (Systemic) may enhance the hypokalemic effect of Loop Diuretics.
Loop Diuretics	Corticosteroids (Orally Inhaled) may enhance the hypokalemic effect of Loop Diuretics.
Nicorandil	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nicorandil. Gastrointestinal perforation has been reported in association with this combination.
Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective)	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective).
Nonsteroidal Anti-Inflammatory Agents (Nonselective)	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents (Nonselective).
Ocrelizumab	May enhance the immunosuppressive effect of Immunosuppressants.
Pidotimod	Immunosuppressants may diminish the therapeutic effect of Pidotimod.
Quinolones	Corticosteroids (Systemic) may enhance the adverse/toxic effect of Quinolones. Specifically, the risk of tendonitis and tendon rupture may be increased.
Ritodrine	Corticosteroids may enhance the adverse/toxic effect of Ritodrine.
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).
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.
Sargramostim	Corticosteroids (Systemic) may enhance the therapeutic effect of Sargramostim. Specifically, corticosteroids may enhance the myeloproliferative effects of sargramostim.
Siponimod	Immunosuppressants may enhance the immunosuppressive effect of Siponimod.
Somatropin	Corticosteroids (Systemic) may diminish the therapeutic effect of Somatropin.
Tacrolimus (Systemic)	Corticosteroids (Systemic) may decrease the serum concentration of Tacrolimus (Systemic). Conversely, when discontinuing corticosteroid therapy, tacrolimus concentrations may increase.
Tertomotide	Immunosuppressants may diminish the therapeutic effect of Tertomotide.
Thiazide and Thiazide-Like Diuretics	Corticosteroids (Systemic) may enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics.
Thiazide and Thiazide-Like Diuretics	Corticosteroids (Orally Inhaled) may enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics.
Tobacco (Smoked)	May diminish the therapeutic effect of Corticosteroids (Orally Inhaled).
Trastuzumab	May enhance the neutropenic effect of Immunosuppressants.
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.
Warfarin	Corticosteroids (Systemic) may enhance the anticoagulant effect of Warfarin.
Risk Factor D (Consider therapy modification)
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.
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.
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.
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.
Echinacea	May diminish the therapeutic effect of Immunosuppressants.
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).
Fosaprepitant	May increase the serum concentration of Corticosteroids (Systemic). The active metabolite aprepitant is likely responsible for this effect.
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.
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.
Mitotane	May decrease the serum concentration of Corticosteroids (Systemic).
Neuromuscular-Blocking Agents (Nondepolarizing)	May enhance the adverse neuromuscular effect of Corticosteroids (Systemic). Increased muscle weakness, possibly progressing to polyneuropathies and myopathies, may occur.
Nivolumab	Immunosuppressants may diminish the therapeutic effect of Nivolumab.
Roflumilast	May enhance the immunosuppressive effect of Immunosuppressants.
Sipuleucel-T	Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Management: Evaluate patients to see if it is medically appropriate to reduce or discontinue therapy with immunosuppressants prior to initiating sipuleucel-T 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).
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.
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.
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 Factor X (Avoid combination)
Aldesleukin	Corticosteroids may diminish the antineoplastic effect of Aldesleukin.
BCG (Intravesical)	Immunosuppressants may diminish the therapeutic effect of BCG (Intravesical).
Cladribine	May enhance the immunosuppressive effect of Immunosuppressants.
Desmopressin	Corticosteroids (Systemic) may enhance the hyponatremic effect of Desmopressin.
Desmopressin	Corticosteroids (Orally Inhaled) may enhance the hyponatremic effect of Desmopressin.
Indium 111 Capromab Pendetide	Corticosteroids (Systemic) may diminish the diagnostic effect of Indium 111 Capromab Pendetide.
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.
Macimorelin	Corticosteroids (Systemic) may diminish the diagnostic effect of Macimorelin.
Mifamurtide	Corticosteroids (Systemic) may diminish the therapeutic effect of Mifamurtide.
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.
Natalizumab	Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased.
Pimecrolimus	May enhance the adverse/toxic effect of Immunosuppressants.
Tacrolimus (Topical)	May enhance the adverse/toxic effect of Immunosuppressants.

Monitoring parameters:

Blood Pressure:

• Keep an eye on blood pressure levels.

Blood Glucose:

• Monitor blood sugar levels regularly.

Electrolytes:

• Check electrolyte levels periodically.

Weight:

• Keep track of weight changes.

Intraocular Pressure:

• Monitor intraocular pressure, especially if using for more than 6 weeks.

Bone Mineral Density:

• Assess bone density, especially with long-term use.

Growth and Development in Children:

• Watch for any impact on growth and development in children.

HPA Axis Suppression:

• Monitor for suppression of the hypothalamic-pituitary-adrenal (HPA) axis.

How to administer Triamcinolone (Kenalog)?

Preparation and Administration Instructions for Triamcinolone

• Shake Well: Ensure the suspension is uniform by shaking well before use.
• Visual Inspection: Check visually for any clumping before administration.
• Immediate Use: Administer immediately after withdrawal to prevent settling in the syringe.
• Route of Administration: Do not administer any product intravenously (IV) or via the epidural or intrathecal route.
• Kenalog-10 Injection:
  • Intra-articular or Intralesional: Use for these routes only.
  • Intralesional Administration: Inject directly into the lesion, preferably with a 23- to 25-gauge needle.
• Kenalog-40 Injection:
  • Intra-articular, Soft Tissue, or IM: Suitable for these administrations.
  • IM Administration: Inject deep into the gluteal muscle using a minimum needle length of 1 ½ inches. Alternate sites for subsequent injections. Avoid the deltoid area for IM injections.
• Zilretta Injection:
  • Intra-articular Only: Use exclusively for intra-articular administration.
  • Preparation and Storage: Prepare suspension only using the diluent provided. Promptly inject after preparation. If needed, the suspension may be stored in the vial for up to 4 hours at ambient conditions. Gently swirl the vial to resuspend any settled microspheres before preparing the syringe for injection.

Hexacetonide (Canadian Product):

• Intra-articular and Soft Tissue Only: Intended for these administrations. Use a 25- or 26-gauge needle for injection.

Mechanism of action of Triamcinolone (Kenalog):

• This medication is a long-acting corticosteroid that minimally retains sodium.
• It works by reducing inflammation through the suppression of the movement of certain white blood cells and reversing increased capillary permeability.
• Additionally, it lowers immune system activity by reducing lymphatic system activity and volume.
• However, at high doses, it can also suppress adrenal function.

Onset and Duration of Adrenal Suppression:

• IM (Acetonide): Onset occurs within 24 to 48 hours.
• Intra-articular: Onset is typically greater than 24 hours.
• Duration:
  • IM (Acetonide): Lasts for 30 to 40 days.
  • Intra-articular: Lasts for 28 to 42 days.

Distribution:

• Volume of Distribution (V):
  • IV (Acetonide): Approximately 99.5 L per day.

Metabolism:

• Hepatic Metabolism: Metabolized in the liver.

Half-life Elimination:

• Plasma: Half-life of elimination is approximately 300 minutes.

Excretion:

• Urine: Approximately 75% of the drug is excreted primarily through urine.
• Bile and Feces: Approximately 25% is excreted through bile and feces.

International Brand Names of Triamcinolone:

• Arze-Ject-A
• Kenalog
• Kenalog-80
• P-Care K40
• P-Care K80
• Pod-Care 100K
• Pro-C-Dure 5
• Pro-C-Dure 6
• ReadySharp Triamcinolone
• Zilretta
• Aristospan
• Kenalog-10
• Kenalog-40
• Acetidrona
• Aftab
• Albicort
• Amcinol
• Aristocort
• Aristocort A
• Atrinat
• Avcort
• Bluxam
• Cenalog
• Cenolon
• Cynocort
• Danizax
• Delphicort
• Deltrianolona
• Epirelefan
• Flamicort
• Forticinolone
• Intralon
• Introlan
• Ioncort
• Kenacort
• Kenacort A
• Kenacort E
• Kenacort IM
• Kenacort Retard
• Kenacort T
• Kenacort-A
• Kenacort-A I.M.
• Kenalog
• Kenalog-40
• Kilcort
• Konicort
• Ledercort
• Lederlon
• Lederspan
• Loncort
• MaQaid
• Maquaid
• Oracort
• Panbicort
• Polkortolon
• Rabeolone
• Rheudenolone
• Shincort
• Sivkort
• Softram
• Solu-Volon
• Sterocort
• Stucort
• T-Cort
• Thainocort
• Tracinone
• Tramsicort
• Trecilon
• Tri-Ject
• Triam
• Triamcort
• TriamHEXAL
• Triamhexal
• Triamon
• Trica
• Tricort
• Trigon Depot
• Trilac
• Trimcort
• Trinakor
• Trincort
• Trispan
• Trispane
• Volon A
• Volon A 10
• Volon A 40

Triamcinolone Brand Names in Pakistan:

Triamcinolone Injection 10 Mg/Ml in Pakistan
Tramacort	Trigon Pharmaceuticals Pakistan (Pvt) Ltd.

Triamcinolone Injection 40 Mg/Ml in Pakistan
Amrokort	Amros Pharmaceuticals.
Cinokort	Polyfine Chempharma (Pvt) Ltd.
Danacort	Danas Pharmaceuticals (Pvt) Ltd
Dexafort	Cirin Pharmaceuticals (Pvt) Ltd.
K-Kort	Ophth-Pharma (Pvt) Ltd.
Kenacort-A	Glaxosmithkline
Lawrcort	Lawrence Pharma
Lonacort	Zafa Pharmaceutical Laboratories (Pvt) Ltd.
M-Kort	Mediate Pharmaceuticals (Pvt) Ltd
Medikort	Medicraft Pharmaceuticals (Pvt) Ltd.
Triam	Z-Jans Pharmaceutical (Pvt) Ltd.
Tricort	Akhai Pharmaceuticals.
Triton Inj	Mass Pharma (Private) Limited
Vibra	Fassgen Pharmaceuticals
Welkort	Welmark Pharmaceuticals

Triamcinolone Oint 0.1 %W/W in Pakistan
Kenalog In Orabase	Glaxosmithkline
Lonacort 0.1%	Zafa Pharmaceutical Laboratories (Pvt) Ltd.

Triamcinolone Cream 1 Mg/G in Pakistan
K-Kort	Ophth-Pharma (Pvt) Ltd.

Triamcinolone Nasal Spray 15 Mg/Actu in Pakistan
Hinase	Hilton Pharma (Pvt) Limited

Triamcinolone Nasal Spray 55 Mcg/Actu in Pakistan
Nasacort-Aq	Sanofi Aventis (Pakistan) Ltd.
Nasarin	Schazoo Zaka

Triamcinolone Paste 10 Mg in Pakistan
Tri-Domec Paste	Platinum Pharmaceuticals (Pvt.) Ltd.

Triamcinolone Tablets 4 Mg in Pakistan
Kenacort	Glaxosmithkline