Triamcinolone is a synthetic glucocorticoid with anti-inflammatory and immunomodulating properties. Upon cell entry, triamcinolone binds to and activates the glucocorticoid receptor, which leads to translocation of the ligand-receptor complex to the nucleus and induces expression of glucocorticoid-responsive genes such as lipocortins. Lipocortins inhibit phospholipase A2, thereby blocking the release of arachidonic acid from membrane phospholipids and preventing the synthesis of prostaglandins and leukotrienes, both mediators of inflammation. In addition, pro-inflammatory cytokine production, including interleukin (IL)-1and IL-6, and the activation of cytotoxic T-lymphocytes is also inhibited. T-cells are prevented from making IL-2 and proliferating. This agent also decreases the number of circulating lymphocytes, induces cell differentiation, and stimulates apoptosis through increasing Ikappa-B expression and curtailing activation of nuclear factor (NF)kappa-B.
A glucocorticoid was given, as the free alcohol or in esterified form, orally, intramuscularly, by local injection, by inhalation, or applied topically in the management of various disorders in which corticosteroids are indicated.
It is also known under the brand names Kenalog (topical) and Volon A as an injection, to treat allergies, arthritis, eye diseases, intestinal problems, and skin diseases. There are possible risks from an injection. It has been known to cause fat and muscle loss at an injection site, leaving a large divot bone deep.
Mechanism of Action of Triamcinolone
Triamcinolone and its derivatives are synthetic glucocorticoids that are used for their anti-inflammatory or immunosuppressive properties. The anti-inflammatory actions of corticosteroids are thought to involve lipocortins, phospholipase A2 inhibitory proteins which, through inhibition of arachidonic acid, control the biosynthesis of prostaglandins and leukotrienes. Firstly, however, these glucocorticoids bind to the glucocorticoid receptors which translocate into the nucleus and bind DNA (GRE) and change genetic expression both positively and negatively. The immune system is suppressed by corticosteroids due to a decrease in the function of the lymphatic system, a reduction in immunoglobulin and complement concentrations, the precipitation of lymphocytopenia, and interference with antigen-antibody binding.
or
Glucocorticoids are capable of suppressing the inflammatory process through numerous pathways. They interact with specific intracellular receptor proteins in target tissues to alter the expression of corticosteroid-responsive genes. Glucocorticoid-specific receptors in the cell cytoplasm bind with steroid ligands to form hormone-receptor complexes that eventually translocate to the cell nucleus. There these complexes bind to specific DNA sequences and alter their expression. The complexes may induce the transcription of mRNA leading to the synthesis of new proteins. Such proteins include lipocortin, a protein known to inhibit PLA2a and thereby block the synthesis of prostaglandins, leukotrienes, and PAF. Glucocorticoids also inhibit the production of other mediators including AA metabolites such as COX, cytokines, the interleukins, adhesion molecules, and enzymes such as collagenase.
Corticosteroids diffuse across cell membranes and complex with specific cytoplasmic receptors. These complexes then enter the cell nucleus, bind to DNA (chromatin), and stimulate transcription of messenger RNA (mRNA) and subsequent protein synthesis of various inhibitory enzymes responsible for the anti-inflammatory effects of topical corticosteroids. These anti-inflammatory effects include inhibition of early processes such as edema, fibrin deposition, capillary dilatation, movement of phagocytes into the area, and phagocytic activities. Later processes, such as capillary production, collagen deposition, and keloid formation also are inhibited by corticosteroids. The overall actions of topical corticosteroids are catabolic.
Indications of Triamcinolone acetonide
- Rheumatoid Arthritis
- Psoriatic Arthritis
- Psoriasis
- Active Pauciarticular juvenile rheumatoid arthritis
- Ankylosing Spondylitis
- Eczema
- Dermatitis
- Atopic Dermatitis
- Psoriasis
- Stomatitis
- Acne Vulgaris
- Acute Gouty Arthritis
- Allergic Rhinitis
- Atopic Dermatitis
- Autoimmune Hemolytic Anemia
- Bullous dermatitis herpetiformis
- Congenital Adrenal Hyperplasia
- Congenital Hypoplastic Anemia
- Crohn’s Disease
- Dermatitis
- Dermatomyositis
- Discoid Lupus Erythematosus
- Edema of the cerebrum
- Epicondylitis
- Hemangiomas
- Hypercalcemia
- Inflammation of Mouth
- Juvenile Idiopathic Arthritis
- Keloid Scars
- Leukemia
- Malignant Lymphomas
- Mycosis Fungoides
- Necrobiosis lipoidica diabeticorum
- Ophthalmia, Sympathetic
- Pericarditis
- Polymyositis
- Post-Herpetic Neuralgia
- Primary adrenocortical insufficiency
- Proteinuria
- Psoriatic Arthritis
- Psoriatic plaque
- Rheumatoid Arthritis
- Secondary adrenocortical insufficiency
- Secondary thrombocytopenia
- Skin Inflammation
- Synovitis
- Systemic Lupus Erythematosus
- Temporal Arteritis
- Tuberculosis
- Ulcerative Colitis
- Uveitis
- Acute Bursitis
- Multiple sclerosis
- Acute Rheumatic heart disease
- Acute Tenosynovitis
- Cystic tumor of the ganglia
- Exfoliative erythroderma
- Granuloma annulare lesions
- Idiopathic eosinophilic pneumonia
- Non-suppurative Thyroiditis
- Ocular inflammatory conditions
- Severe Erythema multiforme
- Symptomatic Sarcoidosis
- Unresponsive to topical ocular inflammation
Therapeutic Uses Triamcinolone
- Triamcinolone acetonide is effective in the treatment of acute traumatic synovitis and capsulitis in horses with no deleterious side effects.
- Triamcinolone is indicated as primary maintenance treatment in patients with persistent symptoms of chronic bronchial asthma. Treatment with inhaled corticosteroids is indicated in asthmatic patients whose conditions require anti-inflammatory treatment and in patients dependent on oral corticosteroids who may benefit from a gradual withdrawal from oral corticosteroids to decrease the likelihood of side effects.
- Regular, continuous use of inhaled corticosteroids controls chronic airway inflammation, decreases airway hyperresponsiveness, prevents asthma symptoms, reduces the frequency of asthma exacerbations, and reduces hospital admissions for asthma. Clinical studies have also reported that regular use with inhaled corticosteroids is associated with decreased mortality. Inhaled corticosteroids are effective in all types of asthma and in patients of all ages.
- Triamcinolone shares the actions of the other topical corticosteroids and is used for the relief of the inflammatory manifestations of corticosteroid-responsive dermatoses. The drug is also used as a paste for adjunctive treatment to provide temporary relief of symptoms associated with oral inflammatory or ulcerative lesions resulting from trauma.
- Triamcinolone acetonide nasal inhalation aerosol and aqueous suspension are used for the symptomatic treatment of seasonal or perennial allergic rhinitis. In patients with seasonal or perennial allergic rhinitis, intranasal administration of triamcinolone acetonide generally provides symptomatic relief of rhinorrhea, nasal congestion, sneezing, and itching. In addition to relief of nasal symptoms, improvement of ophthalmic signs and symptoms (e.g., itching, lacrimation) has occurred in some patients, possibly secondary to systemic absorption of the drug. Since intranasal triamcinolone acetonide is thought to exert a local effect on the nasal mucosa, the mechanism of these ophthalmic effects is not fully understood. In patients with seasonal or perennial rhinitis, symptomatic relief usually is evident within several days of continuous intranasal triamcinolone acetonide therapy; however, about 1-2 weeks of continuous therapy may be required for optimum effectiveness in some patients. Onset of response occasionally occurs within 10-16 hours following initiation of intranasal triamcinolone acetonide suspension in patients with seasonal or perennial allergic rhinitis
- Nasal corticosteroids are indicated in the treatment of seasonal or perennial allergic or (vasomotor nonallergic rhinitis NOT included in US package labeling). in patients who have exhibited significant side effects from, or have exhibited poor response to, other therapies, such as antihistamines and decongestants. Antihistamines and decongestants are generally considered primary therapies for these disorders. However, some clinicians consider nasal corticosteroids primary therapy for perennial or seasonal rhinitis because they are more effective if prophylaxis is started two to four weeks prior to exposure to allergens.
- Age-related macular degeneration is now considered an important and leading cause of blindness among elderly patients in developed and developing countries. Age-related macular degeneration has two forms, dry and wet; both can lead to visual loss. However, the occurrence of the subfoveal choroidal neovascular membrane in the wet form results in severe visual impairment. Treatment options for choroidal neovascularization are available in order to maintain and in some cases improve vision. Photodynamic therapy has been used to treat both classic and occult membranes. It was known to cause choroidal hypoperfusion and production of vascular endothelial growth factor. Intravitreal steroid can possibly reduce the damage caused due to these undesirable effects. In the recent past, intravitreal injection of triamcinolone acetonide has been used extensively as an adjunct to photodynamic therapy in age-related macular degeneration in order to reduce the number of photodynamic therapy sessions and evaluate possible beneficial effects on vision.
- Nasal corticosteroids are indicated in the treatment of allergic or inflammatory nasal conditions and nasal polyps.
- Formulations of triamcinolone acetonide high potency gels and very high potency ointments also are used in the treatment of aphthous stomatitis. These agents also are used to treat other gingival disorders, such as desquamative gingivitis and oral lichen planus when the diagnosis has been confirmed by biopsy testing. Gel formulations of high potency corticosteroids and dental triamcinolone are used in the treatment of lichen planus of the mucous membranes.
- Triamcinolone acetonide dental paste is indicated for the adjunctive treatment and temporary relief of symptoms associated with nonherpetic oral inflammatory and ulcerative lesions, including recurrent aphthous stomatitis
- Triamcinolone is used to prevent recurrence of nasal polyps following their surgical removal and sufficient mucosal healing.
- Indicated as adjunctive therapy during an acute episode or exacerbation /of rheumatic disorders. Local injections are preferred when only a few joints or areas are involved: ankylosing spondylitis, acute gouty arthritis, psoriatic arthritis, rheumatoid arthritis (including juvenile arthritis), post-traumatic osteoarthritis, synovitis of osteoarthritis,
- Indicated in the treatment (and prophylaxis NOT included in US product labeling/) of respiratory disorders. Prophylactic uses include administration prior to or during extracorporeal circulation in heart surgery if the patient has a pre-existing pulmonary disorder, and administration prior to, during, and following oral, facial, or neck surgery to prevent edema that may threaten the airway: bronchial asthma, berylliosis, Loeffler’s syndrome (eosinophilic pneumonitis or hypereosinophilic syndrome), aspiration pneumonitis, symptomatic sarcoidosis, disseminated or fulminating pulmonary tuberculosis, and (chronic obstructive pulmonary disease (not controlled with theophylline and beta-adrenergic agonists), idiopathic pulmonary (Hamman-Rich syndrome) fibrosis, and status asthmaticus.
- Triamcinolone is used in the treatment of trichinosis with neurological or myocardial involvement.
- Triamcinolone is indicated concurrently with other immunosuppressants such as azathioprine or cyclosporine to reduce the risk of rejection of transplanted organs.
- Indicated for treatment of oral lesions unresponsive to topical therapy. The presence of an oral herpetic lesion must be ruled out prior to initiation of triamcinolone therapy: desquamative gingivitis, recurrent aphthous stomatitis.
- Indicated in the treatment of severe acute or chronic allergic and inflammatory ophthalmic conditions: chorioretinitis, diffuse posterior choroiditis, allergic conjunctivitis (not controlled topically), herpes zoster ophthalmicus, anterior segment inflammation, iridocyclitis, iritis, keratitis (not associated with herpes simplex or fungal infection), optic neuritis, sympathetic ophthalmia, corneal marginal allergic ulcers, diffuse posterior uveitis and (retrobulbar neuritis /NOT included in US product labeling).
- Indicated during an acute episode or exacerbation (of nonrheumatic inflammatory disorders). Local injections are preferred when only a few joints or areas are involved: epicondylitis and acute nonspecific tenosynovitis.
- Indicated for the treatment of hematologic disorders: acquired hemolytic anemia (autoimmune), congenital hypoplastic anemia (erythroid), red blood cell anemia (erythroblastopenia), secondary thrombocytopenia in adults, idiopathic thrombocytopenic purpura in adults and (hemolysis NOT included in US product labeling).
- Indicated for the treatment of gastrointestinal disorders: ulcerative colitis, Crohn’s disease (Regional enteritis) when systemic therapy is required during a critical period of the disease. Long-term use is not recommended. Indicated for the treatment of dermatologic disorder: alopecia areata, atopic dermatitis, contact dermatitis, exfoliative dermatitis, bullous dermatitis herpetiformis, severe seborrheic dermatitis, severe inflammatory dermatoses, severe erythema multiforme (Stevens-Johnson syndrome), granuloma annulare, keloids, lichen planus, lichen simplex chronicus (neurodermatitis), discoid lupus erythematosus, mycosis fungoides, necrobiosis lipoidica diabeticorum, necrobiosis lipoidica, psoriatic plaques, severe psoriasis, pemphigus, (severe eczema, pemphigoid and localized cutaneous sarcoid
- Indicated during an acute exacerbation or as maintenance therapy (for collagen disorders): acute rheumatic carditis, systemic lupus erythematosus, (relapsing polychondritis, mixed connective tissue disease, polyarteritis nodosa, relapsing polychondritis, and vasculitis.
- Indicated for the treatment of severe or incapacitating allergic disorders intractable to adequate trials of conventional treatment: drug-induced allergic reactions, severe perennial or seasonal allergic rhinitis, and serum sickness.
- Topical corticosteroids of low to medium potency are indicated in the treatment of corticosteroid-responsive dermatologic disorders mild to moderate atopic dermatitis; contact dermatitis; mild nummular dermatitis; seborrheic dermatitis (facial and intertriginous areas); other mild to moderate forms of dermatitis; other mild to moderate inflammatory dermatoses; intertrigo; lichen planus (facial and intertriginous areas); discoid lupus erythematosus (facial and intertriginous areas); polymorphous light eruption; anogenital pruritus; pruritus senilis; psoriasis (facial and intertriginous areas); xerosis (inflammatory phase. Occlusive dressings also may be required for chronic or severe cases of lichen simplex chronicus, psoriasis, eczema, atopic dermatitis, or chronic hand eczema. The more potent topical corticosteroids and or occlusive dressings may be required for conditions such as discoid lupus erythematosus, lichen planus, granuloma annulare, psoriatic plaques, and psoriasis affecting the palms, soles, elbows, or knees. Corticosteroids (topical);
- Triamcinolone is indicated to relieve fever and inflammation from pericarditis.
- Indicated for the treatment of endocrine disorders: acute adrenocortical insufficiency and chronic primary adrenocortical insufficiency (Addison’s disease), secondary adrenocortical insufficiency, congenital adrenal hyperplasia, Cushing’s syndrome (diagnosis), hypercalcemia associated with neoplasms, and nonsuppurative thyroiditis.
Contra-Indications of Triamcinolone acetonide
- Extreme Loss of Body Water
- The condition resulting from a defective immune system
- Decreased Function of Bone Marrow
- Low blood counts due to bone marrow failure
- Defective Growth of Bone Marrow
- Severe anemia
- Severely Decreased Platelets
- Decreased white blood cells
- Alcoholism
- Escape of Fluid into the Lungs
- Interstitial Pneumonitis
- Lung Fibrosis
- Canker Sore
- Ulcer from Stomach Acid
- Ulcerated Colon
- Hardening of the Liver caused by Alcohol
- Hardening of the Liver
- Excess Liver Fibrous Tissue
- Severe liver disease
- Kidney disease with the reduction in kidney function
- Diarrhea
- Ascites
- Abnormal liver function tests
- Pregnancy
- A mother who is producing milk and breastfeeding
- Allergies to Folic Acid Antagonist & Methotrexate Analogues
Dosage of Triamcinolone
Strengths: 1 mg; 2 mg; 8 mg; 40 mg
40 mg/mL; 10 mg/mL; 3 mg/mL; 75 mcg/inh;acetonide
Osteoarthritis
- Intra-Articular (IA) Administration; may use 10 mg/mL or 40 mg/mL injectable suspension
- Smaller joints: 2.5 to 5 mg (up to 10 mg)
- Larger joints: 5 to 15 mg (up to 40 mg)
- Maximum dose: For single injections into several joints, up to a total of 20 mg or more (using 10 mg/mL concentration) OR 80 mg (using 40 mg/mL concentration) have been used
- Maximum frequency: Every 3 to 4 weeks; injection should be as infrequent as possible to avoid possible joint destruction
Extended-release: 32 mg/5 mL
- For Osteoarthritic Knee Pain only: 32 mg as a single intra-articular injection
Ankylosing Spondylitis
Intra-Articular (IA) Administration
- Smaller joints: 2.5 to 5 mg (up to 10 mg)
- Larger joints: 5 to 15 mg (up to 40 mg)
- Maximum dose: For single injections into several joints, up to a total of 20 mg or more (using 10 mg/mL concentration) OR 80 mg (using 40 mg/mL concentration) have been used
- Maximum frequency: Every 3 to 4 weeks; injection should be as infrequent as possible to avoid possible joint destruction
Rheumatoid Arthritis
Intra-Articular (IA) Administration
- Smaller joints: 2.5 to 5 mg (up to 10 mg)
- Larger joints: 5 to 15 mg (up to 40 mg)
- Maximum dose: For single injections into several joints, up to a total of 20 mg or more (using 10 mg/mL concentration) OR 80 mg (using 40 mg/mL concentration) have been used
- Maximum frequency: Every 3 to 4 weeks; injection should be as infrequent as possible to avoid possible joint destruction
Psoriatic Arthritis
Intra-Articular (IA) Administration
- Smaller joints: 2.5 to 5 mg (up to 10 mg)
- Larger joints: 5 to 15 mg (up to 40 mg)
- Maximum dose: For single injections into several joints, up to a total of 20 mg or more (using 10 mg/mL concentration) OR 80 mg (using 40 mg/mL concentration) have been used
- Maximum frequency: Every 3 to 4 weeks; injection should be as infrequent as possible to avoid possible joint destruction
Gouty Arthritis
Intra-Articular (IA) Administration
- Smaller joints: 2.5 to 5 mg (up to 10 mg)
- Larger joints: 5 to 15 mg (up to 40 mg)
- Maximum dose: For single injections into several joints, up to a total of 20 mg or more (using 10 mg/mL concentration) OR 80 mg (using 40 mg/mL concentration) have been used
- Maximum frequency: Every 3 to 4 weeks; injection should be as infrequent as possible to avoid possible joint destruction.
Synovitis
Intra-Articular (IA) Administration
- Smaller joints: 2.5 to 5 mg (up to 10 mg)
- Larger joints: 5 to 15 mg (up to 40 mg)
- Maximum dose: For single injections into several joints, up to a total of 20 mg or more (using 10 mg/mL concentration) OR 80 mg (using 40 mg/mL concentration) have been used
Multiple Sclerosis
- 160 mg IM once a day for 1 week; then 64 mg IM every other day for 1 month
Bursitis
Intra-Articular (IA) Administration
- Smaller joints: 2.5 to 5 mg (up to 10 mg)
- Larger joints: 5 to 15 mg (up to 40 mg)
- Maximum dose: For single injections into several joints, up to a total of 20 mg or more (using 10 mg/mL concentration) OR 80 mg (using 40 mg/mL concentration) have been used
- Maximum frequency: Every 3 to 4 weeks; injection should be as infrequent as possible to avoid possible joint destruction
Anti-inflammatory
- Initial dose: 60 mg IM deep into the gluteal muscle
- Dose adjustments within the range of 40 to 80 mg are generally adequate
- Dose ranges of 2.5 to 100 mg have been used; in certain overwhelming, acute, life-threatening situations, much higher doses may be used
Psoriasis
- Use 10 mg/mL concentration only; multiple sites may be injected, separated by 1 cm or more
- May repeat at weekly or less frequent intervals as necessary
Keloids
- Use 10 mg/mL concentration only; multiple sites may be injected, separated by 1 cm or more
- May repeat at weekly or less frequent intervals as necessary
Allergic Rhinitis
- 40 to 100 mg IM once
Side Effects of Triamcinolone acetonide
The most common
- Mouth sores,
- Drying of the skin
- Change in skin color
- Diarrhea
- Any signs of infection, or a skin rash.
- Stomach pain, especially if it comes along with fever and diarrhea or constipation
- Yellowing of the skin or eyes
- Loss of appetite
- Constipation
- Sleepiness or unusual drowsiness
- Clumsiness or unsteadiness
- Dizziness
- Drowsiness
- Dry mouth
- false sense of well-being
- increased watering of mouth
- lightheadedness
- constipation;
- vision changes;
- breast swelling (in men or women); or
- decreased sex drive, impotence, or difficulty having an orgasm.
- blurred vision, tunnel vision, eye pain or swelling, or seeing halos around lights;
- restless muscle movements in your eyes, tongue, jaw, or neck;
Common
- Drowsiness and lightheadedness the day after taking the medicine.
- Confusion.
- Numbed emotions.
- Visual disturbances such as blurred vision or double vision.
- Shaky movements and unsteady walk (ataxia).
- Loss of memory (amnesia).
- Muscle weakness.
- Dizziness.
- A headache.
- Skin rashes.
- Disturbances of the gut such as diarrhea, constipation, nausea, vomiting or abdominal pain.
- Difficulty in passing urine (urinary retention).
- Changes in sex drive.
- Low blood pressure (hypotension).
- Blood disorders.
- Jaundice.
- Unexpected aggression, restlessness or irritability (tell your doctor if you experience this).
- Nightmares or hallucinations (tell your doctor if you experience this).
Rare
- agitation
- anxiety
- behavioral changes, including aggressiveness, angry outbursts, bizarre behavior, or decreased inhibitions
- confusion
- increased trouble sleeping
- memory problems
- muscle spasms
- shortness of breath
Drug Interactions of Triamcinolone
Triamcinolone may interact with following drugs, supplyments, & may change the efficacy of drugs
- abatacept
- anakinra
- Amphotericin B
- Antibiotics
- Anticholinesterase agents such as donepezil, rivastigmine, and galantamine
- Anticoagulants such as warfarin
- Antidiabetic agents
- anti-tumor necrosis factor agents (e.g., adalimumab, etanercept, infliximab, )
- azathioprine
- “azole” antifungals (e.g., itraconazole, ketoconazole, voriconazole)
- beta-blockers (e.g., carvedilol, metoprolol, propranolol)
- carbamazepine
- clonidine
- clozapine
- corticosteroids (e.g.dexamethasone, hydrocortisone, prednisone)
- cyclosporine
- diltiazem
- imatinib
- Estrogens, including oral contraceptives
- macrolide antibiotics (e.g., clarithromycin, erythromycin)
- methotrexate
- methyldopa
- mycophenolate
- phenobarbital
- phenytoin
- rituximab
- tacrolimus
- verapamil
The above list is not the sufficient drugs interactions list, please always consult your doctor or pharmacist before taking this drug.
Pregnancy & Lactation of Triamcinolone
AU TGA pregnancy category: A
AU TGA pregnancy category: C (acetate suspension)
US FDA pregnancy category: C
Pregnancy
This drug should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. AU TGA pregnancy category: B3 US FDA pregnancy category: C Comments: Topical corticosteroids should not be used extensively on pregnant patients, in large amounts or for extended periods of time.
Lactation
Caution is recommended. Excreted into human milk: Unknown Excreted into animal milk: Data not available Comments: -The effects in the nursing infant are unknown. -Topical steroids should not be applied to the breasts prior to breastfeeding.
References
