Triamcino acetonide cream usp 0.1 la gi
Huyết khối; rối loạn tâm thần kèm theo các triệu chứng cảm xúc; suy vỏ thượng thận, triệu chứng giả Cushing, cân bằng protein giảm, trẻ chậm lớn, đái tháo đường, khả năng đề kháng giảm, bộc phát các bệnh tiềm tàng như bệnh lao, đái tháo đường; loãng xương, teo da và cơ, khó liền vết thương; glaucoma, đục nhân mắt dưới bao phía sau. Show Hiếm gặpTăng áp lực nội sọ, viêm mạch hoại tử, viêm tắc tĩnh mạch, tình trạng nhiễm trùng nặng thêm, mất ngủ, ngất, choáng phản vệ, tăng áp lực nội sọ lành tính kèm theo nôn, đau đầu, phù gai thị do phù não, viêm mũi hoặc eczema tiềm tàng. Dùng thuốc ở liều điều trị gây ức chế bài tiết hormone hướng vỏ thượng thận ở tuyến yên gây teo tuyến thượng thận. Ngừng hoặc giảm liều đột ngột, hoặc tăng nhu cầu corticosteroid do stress, nhiễm trùng, chấn thương, phẫu thuật có thể thúc đẩy suy thượng thận cấp. Triệu chứng suy thượng thận là: Khó chịu, yếu cơ, thay đổi tâm thần, đau cơ, khớp, tróc da, khó thở, chán ăn, buồn nôn, nôn, sốt, hạ đường huyết, hạ huyết áp, mất nước, dẫn đến chết nếu ngừng thuốc đột ngột. Thời gian và liều dùng thuốc là các yếu tố quan trọng trong ức chế đáp ứng tuyến yên - thượng thận đối với stress do ngừng thuốc. Cơ địa của từng cá thể cũng rất quan trọng. Do vậy luôn phải ngừng thuốc từ từ tùy thuộc vào đáp ứng của từng cá thể. Không xác định tần suấtĐau lưng, đau bụng, phân đen, giảm thị lực, khô miệng, mệt mỏi, mất vị giác, kinh nguyệt không đều, vết thâm hoặc bầm tím trên da. Mumbai, Baltimore: Pharma major Lupin announced the launch of Nystatin and Triamcinolone Acetonide Cream USP 100,000 units/gm; 0.1 %, having received an approval from the United States Food and Drug Administration (FDA) earlier. Lupin’s Nystatin and Triamcinolone Acetonide Cream USP 100,000 units/gm; 0.1 % is the generic equivalent of Taro Pharmaceuticals’ Nystatin and Triamcinolone Acetonide Cream. It is indicated for the treatment of cutaneous candidiasis. Nystatin and Triamcinolone Acetonide Cream had annual sales of $54.3 million in the US (IQVIA MAT September 2018). About Lupin Limited Lupin is an innovation led transnational pharmaceutical company developing and delivering a wide range of branded & generic formulations, biotechnology products and APIs globally. The Company is a significant player in the Cardiovascular, Diabetology, Asthma, Pediatric, CNS, GI, Anti-Infective and NSAID space and holds global leadership position in the Anti-TB segment. Lupin is the 13th largest generics pharmaceutical company in terms of market capitalization (30th September 2018, Bloomberg) and the 8th largest generics pharmaceutical company in terms of revenues (30th June 2018, Bloomberg LTM) globally. The Company is the 3rd largest pharmaceutical player in the US by prescriptions for the Total Market (IQVIA MAT September 2018); 3rd largest Indian pharmaceutical company by global revenues (30th June 2018, Bloomberg LTM); 6th largest generic pharmaceutical player in Japan (IQVIA MAT September 2018) and 5th largest company in the Indian Pharmaceutical Market (IQVIA MAT September 2018). For the financial year ended 31st March, 2018, Lupin’s Consolidated sales and Net profits before exceptional items were at Rs. 155,598 million (USD 2.41 billion) and Rs. 13,934 million (USD 216 million) respectively. Please visit http://www.lupin.com for more information. You could also follow us on Twitter – www.twitter.com/lupinglobal CIN: L24100MH1983PLC029442 Registered Office: Lupin Ltd, 3rd Floor, Kalpataru Inspire, Off Western Express Highway, Santacruz (East), Mumbai 400 055. Aristocort, Aristocort A, Aristocort HP, Aristospan, Arze-Ject-A, Children's Nasacort Allergy 24HR Nasal Spray, Cinalog, Cinolar, Flutex, Hexatrione, Kenalog, Kenalog in Orabase, Kenalog-10, Kenalog-40, Kenalog-80, Nasacort, Nasacort AQ, Oralone, Pediaderm TA, Sila III, Triacet, Triamonide, Trianex, Triderm, Triesence, XIPERE, Zilretta HOW SUPPLIEDAristocort/Aristocort A/Aristocort HP/Cinolar/Kenalog/Sila III/Triamcinolone/Triamcinolone Acetonide/Trianex/Triderm Topical Ointment: 0.025%, 0.05%, 0.1%, 0.5% DOSAGE & INDICATIONSFor the treatment of severe or incapacitating asthma maintenance treatment not amenable to oral treatment or not responding to adequate trials of conventional treatment. Intramuscular dosage (triamcinolone acetonide injection suspension, e.g., Kenalog) 60 mg IM is a suggested initial dose. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM. These injections are generally long-acting preparations, and are not suitable for use in acute situations. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given as 3 or 4 divided doses.These injections are generally long-acting preparations, and are not suitable for use in acute situations. For the management of symptoms of seasonal allergies and perennial allergies, including allergic rhinitis. For the treatment of allergic rhinitis not responding to pollen administration and other conventional therapy. Intramuscular dosage (triamcinolone acetonide injection suspension; e.g., Kenalog) Usual dose: 40 to 80 mg IM single dose. Titrate if needed based on response and relief duration. Max: 100 mg IM single dose. Symptom remission during the pollen season may be obtained after a single dose. Nasal dosage (triamcinolone acetonide nasal spray 55 mcg/spray; e.g., Nasacort Allergy 24HR OTC) Initially, 2 sprays into each nostril once daily (total dose of 220 mcg). Dosage should be reduced to the minimum effective dose. Maximum effects usually occur within 1 week of initiation of therapy. If adequate relief of symptoms is not achieved after 3 weeks of treatment, the drug should be discontinued. Children and Adolescents 12 years and older Initially, 2 sprays into each nostril once daily (total dose of 220 mcg). Dosage should be reduced to the minimum effective dose. Maximum effects usually occur within 1 week of initiation of therapy. If adequate relief of symptoms is not achieved after 3 weeks of treatment, the drug should be discontinued. Initially 1 spray into each nostril once daily (total dose of 110 mcg). The dosage may be increased to 2 sprays into each nostril once daily (total dose of 220 mcg) if needed. Once the patient's symptoms are controlled, the dosage should be reduced to the minimum effective dose. Periodically reassess need for continued therapy. Patients and caregivers should consult a health care provider if using non-prescription for more than 2 months. 1 spray into each nostril once daily (total dose of 110 mcg). Higher doses are not recommended. Periodically reassess need for continued therapy. Patients and caregivers should consult a health care provider if using non-prescription for more than 2 months. For the treatment of ocular inflammation (i.e., sympathetic ophthalmia and ocular inflammatory conditions unresponsive to topical corticosteroids), temporal arteritis, and uveitis. Intravitreal/Intraocular injection dosage (Triesence injectable suspension ONLY) The initial recommended dose is 4 mg (100 microL of 40 mg/mL suspension) followed by subsequent dosage as needed over the course of treatment. Intramuscular dosage (triamcinolone acetonide injection suspension; e.g., Kenalog) 60 mg IM is a suggested initial dose. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM. Used when oral therapy is not feasible. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given in 3 or 4 divided doses. For the treatment of macular edema associated with uveitis. Suprachoroidal/Intraocular injection dosage (Xipere injectable suspension ONLY) A single 4 mg (0.1 mL of 40 mg/mL suspension) suprachoroidal injection administered using the SCS Microinjector. For visualization during ocular surgery / ophthalmic surgery (i.e., vitrectomy). Intravitreal injection dosage (Triesence injectable suspension ONLY) 1 to 4 mg (25 to 100 microL of 40 mg/mL suspension) administered intravitreally. For the treatment of acute exacerbations of multiple sclerosis. Intramuscular dosage (triamcinolone acetonide injectable suspension; e.g., Kenalog) 160 mg IM daily for 7 days, then 64 mg IM every other day for 1 month. For the treatment of an acute episode or exacerbation of ankylosing spondylitis. Intramuscular dosage (triamcinolone acetonide injectable suspension; e.g., Kenalog) 60 mg IM is a suggested initial dose. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given as 3 or 4 divided doses. For the treatment of corticosteroid-responsive dermatoses, including atopic dermatitis, localized vitiligo, eczema, phimosis, lichen planus, localized bullous pemphigoid, and contact dermatitis. Topical dosage (0.025% to 0.05% cream, ointment, or lotion) Apply a thin layer topically to the affected skin area(s) 2 to 4 times daily. Apply a thin layer topically to the affected skin area(s) 2 to 4 times daily. Topical dosage (0.1% to 0.5% cream, ointment, or lotion) Apply a thin layer topically to the affected skin area(s) 2 to 3 times daily. Apply a thin layer topically to the affected skin area(s) 2 to 3 times daily. Apply topically to the affected skin area(s) 3 to 4 times daily. Apply topically to the affected skin area(s) 3 to 4 times daily. Intramuscular dosage (triamcinolone acetonide injectable suspension; e.g., Kenalog) 60 mg IM is a suggested initial dose for the treatment of severe conditions when oral treatment is not appropriate or feasible. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given as 3 or 4 divided doses for the treatment of severe conditions when oral treatment is not appropriate or feasible. For temporary relief of symptoms due to oral inflammatory or ulcerative lesions (e.g., aphthous ulcer, mucosal lichen planus, trauma). Topical dosage (triamcinolone acetonide 0.1% dental paste) Apply (dab) a small amount (approx. 1/4 inch) to coat the lesion once daily at bedtime. A larger quantity may be required for coverage of some lesions. Do not rub in. If more severe symptoms are present, may apply 2 or 3 times a day, preferably after meals. Reassess if significant repair or regeneration has not occurred in 7 days. Apply (dab) a small amount (approx. 1/4 inch) to coat the lesion once daily at bedtime. A larger quantity may be required for coverage of some lesions. Do not rub in. If more severe symptoms are present, may apply 2 or 3 times a day, preferably after meals. Use the lowest possible dose in pediatric patients. Reassess if significant repair or regeneration has not occurred in 7 days. For the treatment of bullous dermatitis herpetiformis, exfoliative erythroderma (exfoliative dermatitis), mycosis fungoides, severe erythema multiforme (Stevens-Johnson syndrome), drug hypersensitivity reactions, transfusion reactions, or serum sickness when oral therapy is not feasible. Intramuscular dosage (triamcinolone acetonide injection suspension; e.g., Kenalog) 60 mg IM is a suggested initial dose. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM.
For the treatment of dermatomyositis, polymyositis, or systemic lupus erythematosus (SLE). Intramuscular dosage (triamcinolone acetonide injection suspension; e.g., Kenalog) 60 mg IM is a suggested initial dose. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given as 3 or 4 divided doses. For the treatment of proteinuria or to induce diuresis in idiopathic nephrotic syndrome or lupus nephritis. Intramuscular dosage (triamcinolone acetonide injection suspension; e.g., Kenalog) 60 mg IM is a suggested initial dose. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given as 3 or 4 divided doses. For the treatment of acute rheumatic carditis, berylliosis, symptomatic sarcoidosis, or idiopathic eosinophilic pneumonia. Intramuscular dosage (triamcinolone acetonide injectable suspension; e.g., Kenalog) 60 mg IM is a suggested initial dose. Titrate dose based on patient response and relief duration; usual dose range is 40 to 80 mg IM per day. However, some patients may be well controlled on doses as low as 20 mg or less. General range of dosing 2.5 mg to 100 mg IM. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given as 3 or 4 divided doses. For the treatment of a critical period of regional enteritis (Crohn's disease) or ulcerative colitis. Intramuscular dosage (triamcionolone acetonide injection suspension; e.g., Kenalog) 60 mg IM is a suggested initial dose. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM. Because of the potential complications of steroid use, steroids should be used selectively and in the lowest dose possible for the shortest duration as possible. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given as 3 or 4 divided doses. Because of the potential complications of steroid use, steroids should be used selectively and in the lowest dose possible for the shortest duration as possible. For the treatment of adrenocortical function abnormalities, such as adrenocortical insufficiency, congenital adrenal hyperplasia (CAH), chronic primary (Addison's disease) or secondary adrenocortical insufficiency. Intramuscular dosage (triamcinolone acetonide injection suspension; e.g., Kenalog) 60 mg IM is a suggested initial dose. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM. Hydrocortisone and cortisone are the preferred drugs; triamcinolone has little to no mineralocorticoid properties and should be used in conjunction with mineralocorticoids. Dosing is highly variable. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given as 3 or 4 divided doses. Hydrocortisone and cortisone are the preferred drugs; triamcinolone has little to no mineralocorticoid properties and should be used in conjunction with mineralocorticoids. Dosing is highly variable. For the treatment of nonsuppurative thyroiditis. Intramuscular dosage (triamcinolone acetonide injection suspension; e.g., Kenalog) 60 mg IM is a suggested initial dose. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given as 3 or 4 divided doses. For the adjunctive treatment of hypercalcemia associated with cancer. Intramuscular dosage (triamcinolone acetonide injection suspension; e.g., Kenalog) 60 mg IM is a suggested initial dose. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM. Triamcinolone use is not common; hydrocortisone and prednisone are more commonly given. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given as 3 or 4 divided doses. Triamcinolone use is not common; hydrocortisone and prednisone are more commonly given. For the palliative management of leukemias and lymphomas including acute lymphocytic leukemia (ALL), chronic lymphocytic leukemia (CLL), Hodgkin lymphoma, non-Hodgkin's lymphoma (NHL). Intramuscular dosage (triamcinolone acetonide injection suspension; e.g., Kenalog) 60 mg IM is a suggested initial dose. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given as 3 or 4 divided doses. For the treatment of acquired (autoimmune) hemolytic anemia, erythroblastopenia (RBC anemia or pure red cell aplasia), congenital hypoplastic anemia (Diamond-Blackfan anemia) and select cases of secondary thrombocytopenia. Intramuscular dosage (triamcinolone acetonide injection suspension; e.g. Kenalog) 60 mg IM is a suggested initial dose. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given as 3 or 4 divided doses. For the treatment of cerebral edema associated with primary or metastatic brain tumor or craniotomy. Intramuscular dosage (triamcinolone acetonide injection suspension; e.g., Kenalog) 60 mg IM is a suggested initial dose. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given as 3 or 4 divided doses. For the treatment of trichinosis with neurologic or myocardial involvement. Intramuscular dosage (triamcinolone acetonide injection suspension; e.g., Kenalog) 60 mg IM is a suggested initial dose. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given as 3 or 4 divided doses. For the treatment of drug-susceptible tuberculosis infection or drug-resistant tuberculosis infection as adjunctive therapy in combination with antituberculous therapy. Intramuscular dosage (triamcinolone acetonide) 2.13 mg/kg/day IM with a taper over 6 to 8 weeks. Guidelines recommend as adjunct therapy for meningitis. Routine use outside of CNS involvement is not recommended; however, select patients may benefit. Infants, Children, and Adolescents 1.6 to 3.2 mg/kg/day IM for 4 to 6 weeks, then taper over 2 to 4 weeks. Guidelines recommend as adjunct therapy for meningitis. Routine use outside of CNS involvement is not recommended; however, select patients may benefit. For the treatment of psoriasis. Topical dosage (0.025% to 0.05% cream, ointment, or lotion) Apply a thin layer topically to the affected skin area(s) 2 to 4 times daily. Apply a thin layer topically to the affected skin area(s) 2 to 4 times daily. Topical dosage (0.1% to 0.5% cream, ointment, or lotion) Apply a thin layer topically to the affected skin area(s) 2 to 3 times daily. Apply a thin layer topically to the affected skin area(s) 2 to 3 times daily. For the treatment of diabetic macular edema†. Intravitreal injection dosage (Triesence injection suspension ONLY) Dosage not established. 4 mg by intravitreal injection in the affected eye(s) has been used. Steroid therapies are associated with inferior visual acuity outcomes and increased rate of cataracts and glaucoma when compared against intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) agents. For the relief of inflammation associated with acute gouty arthritis, acute and subacute bursitis, acute nonspecific tenosynovitis, epicondylitis, rheumatoid arthritis, juvenile rheumatoid arthritis (JRA)/juvenile idiopathic arthritis (JIA), psoriatic arthritis, synovitis of osteoarthritis, and polychondritis†. For the treatment of osteoarthritis pain of the knee. Intra-articular dosage (extended-release triamcinolone acetonide suspension; Zilretta ONLY) 32 mg intra-articular as a single dose. The efficacy and safety of repeat administration have not been demonstrated; in a study evaluating a repeat intra-articular injection after week 12, there were higher rates of reported mild to moderate arthralgia after the second dose (16%) than after the first dose (6%). Zilretta is not interchangeable with other formulations of triamcinolone acetonide. Intramuscular dosage (triamcinolone acetonide injectable suspension; e.g., Kenalog) 60 mg IM is a suggested initial dose. Titrate to patient response and relief duration. Usual dose range is 40 to 80 mg IM per day. Some patients may be well controlled on doses as low as 20 mg or less. General dose range: 2.5 mg to 100 mg IM. 0.11 to 1.6 mg/kg/day (3.2 to 48 mg/m2/day) IM given as 3 or 4 divided doses. Intra-articular dosage (triamcinolone acetonide injectable suspension; e.g., Kenalog) 2.5 mg to 5 mg for smaller joints and from 5 mg to 15 mg for larger joints, depending on the specific disease entity being treated. For adults, doses up to 10 mg for smaller areas and up to 40 mg for larger areas have usually been sufficient. Single injections into several joints, up to a total of 80 mg, have been given. 2.5 mg to 5 mg for smaller joints and from 5 mg to 15 mg for larger joints, depending on the specific disease entity being treated. Other regimens have been described: 2 mg/kg for large joints (knees, hips, and shoulders) and 1 mg/kg for smaller joints (ankles, wrists, and elbows). For the hands and feet, 2 to 4 mg/joint (metacarpo- or metatarpo-phalangeal) or 1.2 to 2 mg/joint (proximal interphalangeal), may be used. Intra-articular dosage (triamcinolone hexacetonide injection suspension; e.g., Aristospan) 2 to 20 mg intra-articular at appropriate site. In general, large joints (such as knee, hip, shoulder) require 10 to 20 mg. For small joints (such as interphalangeal, metacarpophalangeal), use 2 to 6 mg. Repeat at 3 to 4 week intervals as necessary. 2 to 20 mg intra-articular at an appropriate site. In general, large joints (such as the knee, hip, shoulder) require 10 to 20 mg. For small joints (such as interphalangeal, metacarpophalangeal), use 2 to 6 mg. Repeat at 3 to 4-week intervals as necessary. Other regimens have been described: 1 mg/kg for large joints (knees, hips, and shoulders) and 0.5 mg/kg for smaller joints (ankles, wrists, and elbows). For the hands and feet, 1 to 2 mg/joint (metacarpo- or metatarpo-phalangeal) or 0.6 to 1 mg/joint (proximal interphalangeal), may be used. Intra-articular dosage (triamcinolone hexacetonide injection suspension; e.g., Hexatrione)† 10 mg (0.5 mL) to 40 mg (2 mL) intra-articular at appropriate site without exceeding two 40 mg ampules. Dose dependent on the size of the affected joint. Superficial injection should be avoided because of the risk of skin atrophy. Do not inject into the soft tissue or via intradiscal injection. Repeat injection only if symptoms recur or persist. This formulation is not FDA-approved; the FDA is allowing Medexus to import Hexatrione 2% injectable suspension in response to the shortage of Aristospan. 5 mg (0.25 mL) to 40 mg (2 mL) intra-articular at appropriate site. Do not exceed 40 mg per injection. Adjust dose according to the size of the joint in order to avoid any reflux that could lead to periarticular calcifications and skin atrophy. Do not inject into the soft tissue or via intradiscal injection. Repeat injection only if symptoms reappear or persist, after a minimum of 3 to 6 months compared to the previous administration. Administration is reserved for clinicians with experience in the treatment of rheumatological conditions. This formulation is not FDA-approved; the FDA is allowing Medexus to import Hexatrione 2% injectable suspension in response to the shortage of Aristospan. Intrabursal, Intralesional, or Soft-tissue injection dosage (triamcinolone acetonide injection suspension; e.g., Kenalog) 2.5 mg to 5 mg for smaller areas and from 5 mg to 15 mg for larger areas, depending on the specific disease entity being treated. For adults, doses up to 10 mg for smaller areas and up to 40 mg for larger areas have usually been sufficient. Single injections, up to a total of 80 mg, have been given. In treating acute nonspecific tenosynovitis, ensure that the injection is made into the tendon sheath rather than the tendon substance. For epicondylitis, inflitrate the preparation into the area of greatest tenderness. Intrabursal, Intralesional, or Soft-tissue injection dosage (triamcinolone hexatonide injection suspension; e.g., Aristospan) Dosage may vary depending on the condition and area being treated. Usual range: 2 to 48 mg per day. For the treatment of macular edema following retinal vein occlusion†, including branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO). Intravitreal dosage (preservative-free suspension for injection) 1 or 4 mg by intravitreal injection in the affected eye(s). Guidelines suggest switching to a steroid in nonresponders who have already been treated with anti-vascular endothelial growth factor (VEGF) (after 3 to 6 injections, depending on the specific response of each patient) is reasonable. Steroids may be considered as a first-line therapy for patients who have a recent history of a major cardiovascular event or those who are unwilling to come for monthly injections (and/or monitoring) in the first 6 months of therapy. †Indicates off-label use MAXIMUM DOSAGECorticosteroid dosage must be individualized and is highly variable depending on the nature and severity of the disease, route of administration, and on patient response. DOSING CONSIDERATIONSSystemic dosage may need adjustment depending on the degree of hepatic insufficiency, but quantitative recommendations are not available. Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed. ADMINISTRATIONOral dental paste (e.g., Oralone) Injectable Administration Triamcinolone acetonide or hexatonide injection suspensions are for intramuscular, dermal lesional, or intra-articular injection only. Follow the specific product instructions, as some injections are only formulated for specific routes. Do NOT administer intravenously. Intramuscular Administration Triamcinolone acetonide may be administered by IM injection. Other Injectable Administration Intra-articular, intrasynovial, intrabursal, soft-tissue, intralesional, or sublesional injection suspensions (e.g., Kenalog-10, Kenalog-40, Aristospan) Intra-articular triamcinolone acetonide extended-release microsphere injection suspension (i.e., Zilretta only) Intravitreal injectable suspension (Triesence or Trivaris) Suprachoroidal injectable suspension (Xipere) Cream/Ointment/Lotion Formulations Cream or ointment Other Topical Formulations Topical aerosol spray Inhalation Administration Intranasal Inhalation Administration Nasal Spray Solution (e.g., Nasacort Allergy 24 hour) STORAGEGeneric: CONTRAINDICATIONS / PRECAUTIONSEnsure correct formulation selection, epidural administration, intrathecal administration, intravenous administration, intravitreal administration When using triamcinolone injections, ensure correct formulation selection and the proper route of administration to be used, as there are many dosage forms available. Triamcinolone acetonide or hexacetonide injections should never be given via intravenous administration. Triamcinolone 2% injectable suspension (Hexatrione) should never be injected into the soft tissue or via intradiscal injection. Triamcinolone acetonide injection is not recommended for epidural administration or intrathecal administration. Reports of serious medical events, including death, have been associated with intrathecal or epidural routes of corticosteroid administration. Epidural administration of corticosteroids should be used with great caution. Rare, but serious adverse reactions, including cortical blindness, stroke, spinal cord infarction, paralysis, seizures, nerve injury, brain edema, and death have been associated with epidural administration of injectable corticosteroids. These events have been reported with and without the use of fluoroscopy. Many cases were temporally associated with the corticosteroid injection; reactions occurred within minutes to 48 hours after injection. Some cases of neurologic events were confirmed through magnetic resonance imaging (MRI) or computed tomography (CT) scan. Many patients did not recover from the reported adverse effects. Discuss the benefits and risks of epidural corticosteroid injections with the patient before treatment. If a decision is made to proceed with corticosteroid epidural administration, counsel patients to seek emergency medical attention if they experience symptoms after an injection such as vision changes, tingling in the arms or legs, dizziness, severe headache, seizures, or sudden weakness or numbness of face, arm, or leg. The Triesence product is specifically indicated for intravitreal administration only and Xipere is indicated for suprachoroidal administration; other formulations of triamcinolone acetonide injections are NOT indicated for intraocular use. Triamcinolone acetonide extended-release injectable suspension (Zilretta) is only indicated for intra-articular use in the knee. Corticosteroid hypersensitivity Although true corticosteroid hypersensitivity is rare, patients who have demonstrated a prior hypersensitivity reaction to triamcinolone should not receive any form of triamcinolone. While rare, serious anaphylactoid events have occurred following the administration of parenteral triamcinolone acetonide or hexacetonide injections. It is possible, though also rare, that such patients will display cross-hypersensitivity to other corticosteroids. It is advisable that patients who have a hypersensitivity reaction to any corticosteroid undergo skin testing, which, although not a conclusive predictor, may help to determine if hypersensitivity to another corticosteroid exists. Such patients should be carefully monitored during and following the administration of any corticosteroid. Abrupt discontinuation, adrenal insufficiency, Cushing's syndrome, hypothalamic-pituitary-adrenal (HPA) suppression, increased intracranial pressure, occlusive dressing, skin abrasion Prolonged administration of pharmacological doses of systemic, nasal, inhaled or topical corticosteroids (resulting in systemic absorption) may result in hypothalamic-pituitary-adrenal (HPA) suppression and/or manifestations of Cushing's syndrome in some patients. Adrenal suppression and increased intracranial pressure have been reported with the use and/or withdrawal of various corticosteroid formulations in pediatric patients. Acute adrenal insufficiency and even death may occur following abrupt discontinuation of systemic therapy. In addition, a withdrawal syndrome unrelated to adrenocortical insufficiency may occur following sudden discontinuation of corticosteroid therapy. These effects are thought to be due to the sudden change in glucocorticoid concentration rather than to low corticosteroid concentrations. Withdraw prolonged systemic corticosteroid therapy (duration of treatment more than 2 weeks) gradually. HPA suppression can last for up to 12 months following cessation of systemic therapy. Recovery of HPA axis function is generally prompt and complete upon discontinuation of the topical corticosteroid. HPA-suppressed patients may need supplemental corticosteroid treatment during periods of physiologic stress, such as post-surgical stress, acute blood loss, or infectious conditions, even after the corticosteroid has been discontinued. Encourage patients currently receiving chronic corticosteroid therapy or who have had corticosteroids discontinued within the last 12 months to carry identification advising the need for administration of corticosteroids in situations of increased stress. Conditions that increase systemic absorption of topical corticosteroids include use over large surface areas, prolonged use, use in areas where the epidermal barrier is disrupted (i.e., skin abrasion), and the use of an occlusive dressing. Pediatric patients may absorb proportionally larger amounts of topical corticosteroids compared to adults due to a larger skin surface to body mass ratio and, therefore, may be at increased risk of systemic adverse reactions. Evaluate patients receiving large doses of triamcinolone applied to a large surface area periodically for evidence of HPA axis suppression and/or manifestations of Cushing's syndrome. If these effects are noted, attempt withdrawal of the drug, a reduction in the frequency of application, or substitution of a less potent corticosteroid. Nonprescription intranasal corticosteroids should not be used for greater than 2 months in pediatric patients without oversight of a healthcare provider. If signs of HPA suppression occur with the use of intranasal corticosteroids, the drug should be slowly discontinued. Growth inhibition, osteopenia, osteoporosis Potential adverse effects of chronic corticosteroid therapy should be weighed against the clinical benefits obtained and the availability of other treatment alternatives. Prolonged systemic corticosteroid therapy can lead to osteopenia, osteoporosis, vertebral compression fractures, aseptic necrosis of femoral and humoral heads, and pathologic fractures of long bones secondary to decreased bone formation, increased bone resorption, and protein catabolism in any patients. A high-protein diet may alleviate or prevent the adverse effects associated with protein catabolism. The elderly, post-menopausal, and pediatric patients may be more susceptible to the effects on bone. Chronic systemic triamcinolone therapy may cause growth inhibition in pediatric patients due to hypothalamic-pituitary-adrenal axis suppression and inhibition of bone growth. Corticosteroids should be titrated to the lowest effective dose. Because bone development is critical in pediatric patients, monitoring is warranted in patients receiving high-dose or chronic corticosteroid treatment. Growth inhibition may also occur with intranasal or topical triamcinolone due to systemic absorption, particularly in susceptible patients or when used in high doses or for prolonged periods of time. Use of the lowest effective dose is recommended to minimize the occurrence of systemic adverse effects. Monitor growth routinely. Patients receiving high-dose (e.g., equivalent to 1 mg/kg or more of prednisone daily) or systemic corticosteroid therapy, such as triamcinolone, for any period of time, particularly in conjunction with corticosteroid sparing drugs (e.g., troleandomycin) are at risk to develop immunosuppression; however, patients receiving moderate dosages of systemic corticosteroids for short periods or low dosages for prolonged periods also may be at risk. Treatment with topical or inhaled corticosteroids lessens the risk of immunosuppression; although localized effects may be seen in some patients. When given in combination with other immunosuppressive agents, there is a risk of over-immunosuppression. Intra-articularly injected corticosteroids are systemically absorbed and may cause immunosuppression. Advise patients to contact their health care provider if they develop fever or other signs or symptoms of infection. Joint infections may also occur with intra-articular injection of triamcinolone acetonide extended-release suspension. Avoid injection of triamcinolone into an infected site. Local injection of a corticosteroid into a previously infected joint is not usually recommended. Examine any joint fluid to exclude a septic process. Injection into unstable joints is generally not recommended. If surgery is required, patients should advise their physician that they received prolonged systemic or inhaled corticosteroid therapy, such as triamcinolone, within the last 12 months and state the disease for which they were being treated. For systemic therapy, identification cards that include disease state, type and dose of corticosteroid, and physician should always be carried with the patient. Most triamcinolone injection products are long-acting preparations, and are not suitable for use in acute stress situations. To avoid drug-induced adrenal insufficiency, a supportive corticosteroid dosage may be required in times of stress (such as trauma, surgery, or severe illness) both during treatment with with these injections and for a year afterwards. Fungal infection, helminth infection, infection, viral infection Corticosteroids may increase the risks related to infections with any pathogen, including viral, bacterial, fungal, protozoan, or helminth infection. The degree to which the dose, route and duration of corticosteroid administration correlate with the specific risks of infection is not well characterized, however, with increasing doses of corticosteroids, the rate of occurrence of infectious complications increases. Corticosteroids may also mask some signs of current infection. In general, do not use corticosteroids in patients with systemic fungal infections; corticosteroids can be administered to these patients when necessary as long as appropriate therapy is administered simultaneously. Avoid the use of triamcinolone in patients with a fungal infection or bacterial infection that is not adequately controlled with anti-infective agents. Activation of latent disease or exacerbation of intercurrent infection due to pathogens such as Amoeba, Candida, Cryptococcus, Mycobacterium, Nocardia, Pneumocystis, or Toxoplasma can occur in patients receiving systemic corticosteroids. Rule out infection with latent or active amebiasis before initiating corticosteroid therapy in patients who have spent time in the tropics or who have unexplained diarrhea. Use corticosteroids with caution in patients with known or suspected Strongyloides (threadworm) infestation as the immunosuppressive effects may lead to disseminated infection, severe enterocolitis, and sepsis. Corticosteroids should not be used in patients with cerebral malaria. Reserve systemic corticosteroid therapy in active tuberculosis for patients with fulminating or disseminated disease and only in conjunction with appropriate antituberculosis therapy. Reactivation of tuberculosis may occur in patients with latent tuberculosis or tuberculin reactivity; close observation for disease reactivation is needed if corticosteroids are indicated in such patients. Furthermore, chemoprophylaxis is advised if prolonged corticosteroid therapy is needed. The incidence or course of acute bacterial infection are probably minimally affected by inhaled or nasal triamcinolone. Application of topical corticosteroids to areas of infection, including tuberculosis of the skin, should be initiated or continued only if the appropriate antiinfective treatment is instituted. If the infection does not respond to the antimicrobial therapy, the concurrent use of the topical corticosteroid should be discontinued until the infection is controlled. Herpes infection, measles, varicella Advise patients receiving immunosuppressive doses of systemic corticosteroids to avoid exposure to persons with a viral infection (i.e., measles or varicella) because these diseases may be more serious or even fatal in immunosuppressed patients. Instruct patients to get immediate medical advice if exposure occurs. If exposed to chicken pox, prophylaxis with varicella-zoster immune globulin may be indicated. If exposed to measles, prophylaxis with pooled intramuscular immunoglobulin may be indicated. The incidence or course of acute viral or bacterial infection are probably minimally affected by inhaled or nasal triamcinolone. Application of topical corticosteroids to areas of infection, including dermatologic fungal infection, and cutaneous or systemic viral infection (e.g., herpes infection, measles, varicella), should be initiated or continued only if the appropriate antiinfective treatment is instituted. If the infection does not respond to the antimicrobial therapy, the concurrent use of the topical corticosteroid should be discontinued until the infection is controlled. Use ophthalmic triamcinolone acetonide injectable suspension (Triesence) with caution in patients with ocular herpes infection because of possible corneal perforation. Avoid the use of corticosteroids in active ocular herpes infection due to the risk of corneal perforation. Do not use high doses of systemic corticosteroids such as triamcinolone for the treatment of traumatic brain injury. An increase in early mortality (at 2 weeks) and late mortality (at 6 months) was noted in patients with head trauma who were determined not to have other clear indications for corticosteroid treatment; in the trial, patients received methylprednisolone hemisuccinate. Most triamcinolone injection products are long-acting preparations, and are not suitable for use in acute situations. Heart failure, hypertension, myocardial infarction, renal disease Corticosteroid therapy, including systemic triamcinolone therapy, has been associated with left ventricular free-wall rupture in patients with recent myocardial infarction, and should therefore be used cautiously in these patients. As sodium retention with resultant edema and potassium loss may occur in patients receiving systemic corticosteroids, these agents should be used with caution in patients with congestive heart failure, hypertension, or renal disease or insufficiency. Systemic corticosteroids, such as triamcinolone, may decrease glucose tolerance, produce hyperglycemia, and aggravate or precipitate diabetes mellitus. This may especially occur in patients predisposed to diabetes mellitus. When corticosteroid therapy is necessary in patients with diabetes mellitus, changes in insulin, oral antidiabetic agent dosage, and/or diet may be required. Topical corticosteroids should be used with caution in patients with diabetes mellitus, as increased blood glucose and exacerbation of diabetes has occurred. Use of topical corticosteroids may further delay healing of skin ulcers in diabetic patients. Myasthenia gravis, neuromuscular disease An acute myopathy has been observed with the use of high doses of systemic corticosteroids, most often occurring in patients with neuromuscular disease disorders (e.g., myasthenia gravis), or in patients receiving concomitant therapy with neuromuscular blocking drugs. This acute myopathy is generalized, may involve ocular and respiratory muscles, and may result in quadriparesis. Elevation of creatinine kinase may occur. Clinical improvement or recovery after stopping corticosteroids may require weeks to years. Psychosis, seizure disorder Existing emotional instability or psychosis may be aggravated by corticosteroids. Psychiatric derangements may appear when corticosteroids are used, ranging from euphoria, insomnia, mood swings, personality changes, and severe depression, to frank psychosis. Use triamcinolone with caution in patients with a seizure disorder; systemic steroids can lower the seizure threshold. Hyperthyroidism, hypothyroidism, thyroid disease Metabolic clearance of corticosteroids is decreased in hypothyroidism and increased in hyperthyroidism. Changes in thyroid disease status of a patient may necessitate an adjustment in systemic triamcinolone dosage. Diverticulitis, GI perforation, hepatic disease, peptic ulcer disease, ulcerative colitis Systemic corticosteroids should be used with caution in patients with active or latent peptic ulcer disease, diverticulitis, fresh intestinal anastomoses, and nonspecific ulcerative colitis, since steroids may increase the risk of a gastrointestinal (GI) perforation. Signs of peritoneal irritation following GI perforation in patients receiving corticosteroids may be minimal or absent. Corticosteroids should not be used in patients where there is a possibility of impending GI perforation, abscess, or pyogenic infection. There is an enhanced effect due to decreased metabolism of systemic corticosteroids in patients with severe hepatic disease with cirrhosis. Nasal septal perforation, nasal surgery, nasal trauma As with any long-term topical treatment of the nasal cavity, patients using nasal triamcinolone over several months or longer should be examined periodically for possible changes in the nasal mucosa. Further, because of the inhibitory effect of corticosteroids on wound healing, patients who have experienced recent nasal septal perforation or ulcer, nasal surgery, or nasal trauma should not use a nasal corticosteroid until healing has occurred. Impaired wound healing, peripheral vascular disease, skin atrophy Topical corticosteroids should be used for brief periods, or under close medical supervision in patients with evidence of preexisting skin atrophy. Elderly patients may be more likely to have preexisting skin atrophy secondary to aging. Purpura and skin lacerations that may raise the skin and subcutaneous tissue from deep fascia may be more likely to occur with the use of topical corticosteroids in older adult patients. The use of lower potency topical corticosteroids also may be necessary for some patients. Topical corticosteroids may cause impaired wound healing of non-infected wounds, such as venous stasis ulcers. Use topical triamcinolone preparations with caution in patients with markedly impaired circulation or peripheral vascular disease; skin ulceration has been reported in these patients following topical corticosteroid use. Further, because of the inhibitory effect of corticosteroids on wound healing, patients who have experienced recent nasal septal perforation or ulcer, nasal surgery, or nasal trauma should not use nasal triamcinolone until healing has occurred. Acne rosacea, acne vulgaris Topical corticosteroids, such as triamcinolone, should not be used to treat acne vulgaris, acne rosacea, or perioral dermatitis as they may exacerbate these conditions. Cataracts, glaucoma, herpes simplex virus epithelial keratitis, mycobacterial infection, ocular exposure, ocular infection Use systemic, nasal, intravitreal, and suprachoroidal corticosteroids with caution in patients with glaucoma; corticosteroids can cause increased intraocular pressure with possible damage to the optic nerves. If steroid therapy is continued for more than 6 weeks, intraocular pressure should be monitored. The use of corticosteroids may produce posterior subcapsular cataracts and may enhance the establishment of secondary ocular infection due to bacteria, fungi, or viruses. Treatment with suprachoroidally administered triamcinolone (Xipere) is contraindicated in patients with active or suspected ocular or periocular infections, including most types of viral disease or infection of the cornea and conjunctiva such as herpes simplex virus epithelial keratitis, vaccinia, varicella, and mycobacterial infection of the eye and fungal diseases. Corticosteroids should not be used in active ocular herpes simplex because of possible corneal perforation. The use of systemic corticosteroids is not recommended in the treatment of optic neuritis and may lead to an increase in the risk of new episodes. The use of triamcinolone injections, except for Triesence, by intravitreal administration is not recommended. Endophthalmitis, eye inflammation, increased intraocular pressure, and visual disturbances including vision loss have been reported with intravitreal administration. Several instances of blindness have been reported following injection of corticosteroid suspensions into the nasal turbinates and intralesional injection about the head. Care should be taken to avoid ocular exposure to topical and nasal triamcinolone preparations. Visual impairment, ocular hypertension, and worsened cataracts have been reported with ocular exposure to other high potency topical corticosteroids. Preexisting glaucoma may be aggravated if triamcinolone is applied in the periorbital area. Immune thrombocytopenic purpura (ITP) Intramuscular triamcinolone injections are contraindicated in patients with immune thrombocytopenic purpura (ITP). Indicated vaccination procedures may be undertaken in patients receiving nonimmunosuppressive doses of corticosteroids as replacement therapy (e.g., for Addison's disease). Administration of live or live, attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids. Killed or inactivated vaccines may be administered. However, the response to such vaccines may be diminished and cannot be predicted. The immunosuppressive effects of steroid treatment differ, but many clinicians consider a systemic dose equivalent to either 2 mg/kg/day or 20 mg/day of prednisone as sufficiently immunosuppressive to raise concern about the safety of immunization with live-virus vaccines. In patients who have received high-dose, systemic corticosteroids for 2 weeks or longer, it is recommended to wait at least 3 months after discontinuation of therapy before administering a live-virus vaccine. Systemic triamcinolone use should be approached with caution during pregnancy and should be used during pregnancy only when the anticipated benefit outweighs the potential fetal risk. Human and animal studies suggest that use of systemic corticosteroids during the first trimester of pregnancy is associated with an increased risk of orofacial clefts, intrauterine growth restriction and decreased birth weight. If systemic triamcinolone must be used chronically during pregnancy, the potential risks should be discussed with the patient. Infants born to women receiving large doses of systemic corticosteroids during pregnancy should be monitored for signs of adrenal insufficiency, and appropriate therapy should be initiated, if necessary. Caution is also recommended with the use of nasal triamcinolone. Topical use of triamcinolone during pregnancy should also be approached with caution. Topical corticosteroids, including triamcinolone, should not be used in large amounts, on large areas, or for prolonged periods of time in pregnant women. Guidelines recommend mild to moderate potency topical agents over potent corticosteroids, which should be used in short durations. Fetal growth restriction and a significantly increased risk of low birthweight has been reported with use of potent or very potent topical corticosteroids during the third trimester, particularly when using more than 300 grams. Corticosteroids are generally teratogenic in laboratory animals when administered systemically at relatively low dosage levels. The more potent corticosteroids have been shown to be teratogenic after dermal application in laboratory animals. No studies have been conducted with suprachoroidal injection of triamcinolone acetonide (Xipere) in pregnant patients. It is unknown if this route of administration could be associated with fetal risks; however, systemic exposure following suprachoroidal administration is negligible. Administer during pregnancy only if the potential benefit justifies the potential risk to the infant. There are no adequate data on the effect of triamcinolone on the breastfed infant, or the effects on milk production during breast-feeding. Corticosteroids are secreted in human milk. Reports suggest that steroid concentrations in human milk are 5 to 25% of maternal serum levels, and that total infant daily doses are small, less than 0.2% of the maternal daily dose. Reviewers and an expert panel consider inhaled, nasal, and oral corticosteroids acceptable to use during breast-feeding. It is not known whether ocular or topical administration of triamcinolone could result in sufficient systemic absorption to produce detectable quantities in breast milk. However, most dermatologists stress that topical corticosteroids can be safely used during lactation and breast-feeding. If applied topically, care should be used to ensure the infant will not come into direct contact with the area of application, such as the breast. Increased blood pressure has been reported in an infant whose mother applied a high potency topical corticosteroid ointment directly to the nipples. Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. Benzyl alcohol hypersensitivity, neonates, premature neonates Triamcinolone injection formulas contain the preservative benzyl alcohol and should not be used in neonates, premature neonates, and patients with benzyl alcohol hypersensitivity. Administration of benzyl alcohol to neonates can result in 'gasping syndrome,' which is a potentially fatal condition characterized by metabolic acidosis, and CNS, respiratory, circulatory, and renal dysfunction; it is also characterized by high concentrations of benzyl alcohol and its metabolites in the blood and urine. While the minimum amount of benzyl alcohol at which toxicity may occur is not known, 'gasping syndrome' has been associated with benzyl alcohol dosages greater than 99 mg/kg/day in neonates and low-birth-weight neonates. Additional symptoms may include gradual neurological deterioration, seizures, intracranial hemorrhage, hematologic abnormalities, skin breakdown, hepatic failure, renal failure, hypotension, bradycardia, and cardiovascular collapse. Rare cases of death, primarily in preterm neonates, have been reported. Further, an increased incidence of kernicterus, especially in small, preterm neonates has been reported. Practitioners administering this and other medications containing benzyl alcohol should consider the combined daily metabolic load of benzyl alcohol from all sources. Premature neonates, neonates with low birth weight, and patients who receive a high dose may be more likely to develop toxicity. Use systemic corticosteroids such as triamcinolone with caution in the geriatric patient; the risks and benefits of therapy should be considered for any individual patient, particularly with chronic use. According to the Beers Criteria, systemic corticosteroids are considered potentially inappropriate medications (PIMs) for use in geriatric patients with delirium or at high risk for delirium and should be avoided in these patient populations due to the possibility of new-onset delirium or exacerbation of the current condition. The Beers expert panel notes that oral and parenteral corticosteroids may be required for conditions such as exacerbation of chronic obstructive pulmonary disease (COPD) but should be prescribed in the lowest effective dose and for the shortest possible duration. The federal Omnibus Budget Reconciliation Act (OBRA) regulates medication use in residents of long-term care facilities (LTCFs); the need for continued use of a glucocorticoid, with the exception of topical or inhaled formulations, should be documented, along with monitoring for and management of adverse consequences with intermediate or longer-term systemic use. ADVERSE REACTIONSocular hypertension / Delayed / 6.0-60.0 erythema / Early / 1.0-10.0 arthralgia / Delayed / 6.0-16.0 DRUG INTERACTIONSAbatacept: (Moderate) Concomitant use of immunosuppressives, as well as long-term corticosteroids, may potentially increase the risk of serious infection in abatacept treated patients. Advise patients taking abatacept to seek immediate medical advice if they develop signs and symptoms suggestive of infection. PREGNANCY AND LACTATIONSystemic triamcinolone use should be approached with caution during pregnancy and should be used during pregnancy only when the anticipated benefit outweighs the potential fetal risk. Human and animal studies suggest that use of systemic corticosteroids during the first trimester of pregnancy is associated with an increased risk of orofacial clefts, intrauterine growth restriction and decreased birth weight. If systemic triamcinolone must be used chronically during pregnancy, the potential risks should be discussed with the patient. Infants born to women receiving large doses of systemic corticosteroids during pregnancy should be monitored for signs of adrenal insufficiency, and appropriate therapy should be initiated, if necessary. Caution is also recommended with the use of nasal triamcinolone. Topical use of triamcinolone during pregnancy should also be approached with caution. Topical corticosteroids, including triamcinolone, should not be used in large amounts, on large areas, or for prolonged periods of time in pregnant women. Guidelines recommend mild to moderate potency topical agents over potent corticosteroids, which should be used in short durations. Fetal growth restriction and a significantly increased risk of low birthweight has been reported with use of potent or very potent topical corticosteroids during the third trimester, particularly when using more than 300 grams. Corticosteroids are generally teratogenic in laboratory animals when administered systemically at relatively low dosage levels. The more potent corticosteroids have been shown to be teratogenic after dermal application in laboratory animals. No studies have been conducted with suprachoroidal injection of triamcinolone acetonide (Xipere) in pregnant patients. It is unknown if this route of administration could be associated with fetal risks; however, systemic exposure following suprachoroidal administration is negligible. Administer during pregnancy only if the potential benefit justifies the potential risk to the infant. There are no adequate data on the effect of triamcinolone on the breastfed infant, or the effects on milk production during breast-feeding. Corticosteroids are secreted in human milk. Reports suggest that steroid concentrations in human milk are 5 to 25% of maternal serum levels, and that total infant daily doses are small, less than 0.2% of the maternal daily dose. Reviewers and an expert panel consider inhaled, nasal, and oral corticosteroids acceptable to use during breast-feeding. It is not known whether ocular or topical administration of triamcinolone could result in sufficient systemic absorption to produce detectable quantities in breast milk. However, most dermatologists stress that topical corticosteroids can be safely used during lactation and breast-feeding. If applied topically, care should be used to ensure the infant will not come into direct contact with the area of application, such as the breast. Increased blood pressure has been reported in an infant whose mother applied a high potency topical corticosteroid ointment directly to the nipples. Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. MECHANISM OF ACTIONGlucocorticoids prevent or suppress inflammation and immune responses when administered at pharmacological doses. At the molecular level, unbound glucocorticoids readily cross cell membranes and bind with high affinity to specific cytoplasmic receptors. This binding induces a response by modifying transcription and, ultimately, protein synthesis to achieve the steroid's intended action. Such actions can include: inhibition of leukocyte infiltration at the site of inflammation, interference in the function of mediators of inflammatory response, and suppression of humoral immune responses. Some of the net effects include reduction in edema or scar tissue and a general suppression in immune response. The anti-inflammatory actions of corticosteroids are thought to involve phospholipase A2 inhibitory proteins, collectively called lipocortins. Lipocortins, in turn, control the biosynthesis of potent mediators of inflammation such as prostaglandins and leukotrienes by inhibiting the release of the precursor molecule arachidonic acid. The degree of clinical effect and the numerous adverse effects related to corticosteroid use usually depend on the dose administered and the duration of therapy. Early anti-inflammatory effects of topical corticosteroids include the inhibition of macrophage and leukocyte movement and activity in the inflamed area by reversing vascular dilation and permeability. Later inflammatory processes such as capillary production, collagen deposition, and keloid (scar) formation also are inhibited by corticosteroids. Clinically, these actions correspond to decreased edema, erythema, pruritus, plaque formation, and scaling of the affected skin. In the treatment of allergies, intranasal triamcinolone inhibits the activity of several cell types (e.g., mast cells and eosinophils) and mediators (e.g., histamine, eicosanoids, leukotrienes, and cytokines) involved in the allergic response. Clinically, symptoms such as rhinorrhea and postnasal drip, nasal congestion, sneezing, and pharyngeal itching are reduced. Although the exact mechanisms for the anti-edematous, anti-inflammatory, and antiangiogenic actions of triamcinolone in the treatment of macular edema are unclear, a proposed mechanism of action is that ocular injection of triamcinolone increases the levels of right-junction proteins, thereby diminishing vessel leakage and angiostatic actions through vascular endothelial growth factor (VEGF) inhibition and down regulation. PHARMACOKINETICSTriamcinolone is administered topically, nasally, or by intramuscular, intra-articular, intravitreal, and suprachoroidal injection. It has also been administered by orally and by respiratory inhalation, although these dosage forms are no longer marketed. The onset and duration of action of triamcinolone injection suspensions depend on the route of administration and the extent of the local blood supply. The circulating drug binds weakly to plasma proteins, and only the unbound portion of the drug is active. Corticosteroids are metabolized primarily in the liver and are then excreted by the kidneys; some corticosteroids and their metabolites are also excreted into the bile. Systemic triamcinolone is quickly distributed into the kidneys, intestines, skin, liver, and muscle. Corticosteroids distribute into breast milk and cross the placenta. Any systemically absorbed triamcinolone is metabolized by the liver; 3 metabolites have been identified that have little to no activity compared to the parent compound. Approximately 40% of the administered dose is excreted in the urine, and 60% in the feces, primarily as the metabolites. The plasma half-life of triamcinolone is approximately 88 minutes following an intravenous dose. However, the plasma half-life of the corticosteroids does not correlate well with the biologic half-life of the drugs. Some triamcinolone formulas, like the injection suspension, have prolonged durations of action which may be sustained over a period of several weeks (e.g., 30 to 40 days). The extended-release suspension injection has an even longer duration of action when given into a joint. Affected Cytochrome P450 (CYP450) isoenzymes and drug transporters: Not documented. Oral mucosal application Studies indicate that following a single IM dose of 60 mg to 100 mg of triamcinolone acetonide injection suspension, adrenal suppression occurs within 24 to 48 hours and then gradually returns to normal, usually in 30 to 40 days. The metabolism and excretion of any systemically absorbed drug occurs similar to that of intravenously administered drug. Bioavailability following topical application of triamcinolone is dependent on the condition of the skin at the application site. The extent of absorption through the skin is determined by multiple factors including the vehicle, the integrity of the skin barrier, the duration of therapy, and the presence of inflammation and/or other disease processes. Absorption of topical preparations is increased in areas of skin damage, inflammation, or occlusion, or where the stratum corneum is thin such as the eyelids, genitalia, and face. Topical preparations are generally metabolized in the skin, but a small amount may be absorbed systemically. |