Triamcinolone


Article Author:
Gursharan Sidhu


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Charles Preuss


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Updated:
9/24/2019 7:03:11 PM

Indications

Triamcinolone is an FDA approved synthetic corticosteroid drug used in the treatment of various skin conditions including atopic dermatitis, contact dermatitis (e.g., poison ivy), eczema, bullous dermatitis herpetiformis, psoriasis, lichen planus, lichen sclerosis, subacute cutaneous lupus erythematosus, dermatomyositis, seasonal or allergic rhinitis, and others. Triamcinolone may also be used to provide symptomatic relief in chronic asthma, rheumatoid arthritis, gouty arthritis, and osteoarthritis. Although hydrocortisone is the preferred drug in the treatment of Addison disease and secondary adrenocortical insufficiency, triamcinolone may also serve as a second-line drug. Triamcinolone is given as a prescription by the primary care physician and topically available as an over-the-counter medication. Triamcinolone comes under several brand names.[1][2][3][4]

Mechanism of Action

Triamcinolone falls under the class of corticosteroids—specifically a glucocorticoid. It exhibits anti-inflammatory and immunosuppressant activity via inhibiting the phospholipase A2 enzyme on the cell membrane phospholipid layer, and thereby hinders the breakdown of leukocyte lysosomal membranes and prevents the formation of arachidonic acid. It ultimately decreases the expression of cyclooxygenase (COX) and lipoxygenase (LOX) and thus prevents the biosynthesis of prostaglandins and leukotrienes, respectively. Corticosteroids manifest anti-inflammatory effects via inhibiting macrophage and leukocyte migration to the affected site by reversing vascular dilation and permeability. These actions lead to reduced edema, erythema, and pruritus. An important anti-inflammatory mechanism gets mediated by the inhibition of nuclear factor kappa-B (NF-kappa-B) which leads to decrease protein expression of interleukin-6 (IL-6), interleukin-8 (IL-8), monocyte chemoattractant protein-1 (MCP-1), COX-2.

Triamcinolone metabolism is primarily hepatic, and elimination is via both renal and fecal pathways. The onset of action and duration of triamcinolone varies because it depends on the route of administration in the body. The medication has a rapid rate of absorption in the body following oral intake. Triamcinolone has a half-life of between 18 to 36 hours, and peak concentrations of triamcinolone occur within 1.5 to 2 hours following oral administration.[5][6][7]

Administration

Triamcinolone administration can be orally (e.g., tablets or capsules), topically (e.g., cream and ointment), oral or intranasal inhalation (e.g., spray), intramuscularly or via intravitreal injection. Triamcinolone, when given orally, should be taken with meals to avoid GI discomfort. When given as a topical form, it is instructed to apply a thin layer to the affected area and rub gently. When administered as an inhalation solution, the patient must learn the proper administration technique for the correct dose.[8]

For chronic asthma:

  • IM form:
    • In adults; dose range between 40 to 80 mg IM daily 
    • In pediatrics; dose range 0.11 to 1.6 mg/kg/day divided into 3 or 4 doses 
  • Oral inhalation form:
    • In adults; 150 mcg by mouth three times daily or 300 mcg orally twice daily - *Do not exceed 1200 mcg per day
    • In children between age 6 to 12; dose range 75 to 150 mcg orally three times daily or 150 to 300 mcg orally twice daily - *Do not exceed 900 mcg per day.
    • In children between age 2 to 5; a low dose of 300 mcg orally each day is advised

For seasonal allergies:

  • intranasal inhalation form:
    • In adults and children ages 12 and older; 220 mcg daily (two sprays in each nostril)
    • In children between age 2 to 11; 110 mcg daily (1 spray in each nostril)   *Do not exceed 110 mcg daily in children under the age of 6 

For the treatment of various skin conditions (atopic dermatitis, contact dermatitis, dermatitis herpetiformis, psoriasis, eczema or lichen planus):

  • Topical form:
    • In adults; apply 0.1% triamcinolone paste twice or three times daily to the affected area after meals

For dermatomyositis or symptomatic sarcoidosis:

  • IM form:
    • In adults; dose range between 40 to 80 mg IM daily
    • In pediatrics; dose range 0.11 to 1.6 mg/kg/day divided into 3 or 4 doses 
  • Topical form:
    • In adults; apply either 0.025% to 0.05% cream/ointment, or 0.1% to 0.5% cream/ointment twice or three times daily to the affected area 

For Addison disease or adrenocortical insufficiency:

  • Oral form:
    • In adults; 4-12 mg orally each day
    • In pediatrics; 117 mcg orally each day

For symptomatic relief of rheumatoid arthritis, gouty arthritis, osteoarthritis: 

  • Oral form:
    • In adults; 4 to 48 mg orally each day
    • In pediatrics; 416 mcg to 1.7mg orally each day
  • IM form:
    • In adults; dose range between 40 to 80 mg IM, repeat every 4 weeks 
    • In pediatrics; 40 mg IM, repeat every 4 weeks

Adverse Effects

Common adverse effects associated with the initial use of topical triamcinolone involve itchiness, burning, irritation, or drying of the skin. These symptoms resolve on their own within a few days of use. Other adverse effects may include headaches, dizziness, edema of the ankles or feet, or changes in urination or vision. Chronic use of glucocorticoids such as triamcinolone may cause "Cushing syndrome"; hypertension, weight gain, acne, striae, thinning of the dermal skin layer, osteoporosis, hyperglycemia, amenorrhea, immunosuppression, and steroid psychosis (e.g., depression or mania). 

Patients with congestive heart failure or severe hypertension may experience higher incidences of edema and weight gain when taking triamcinolone. Glucocorticoid drugs must be slowly tapered off with chronic use to prevent the occurrence of adrenal insufficiency (high risk if the drug is abruptly discontinued, especially in very ill patients).[9][10][11]

Contraindications

Triamcinolone injections are strongly contraindicated for epidural administration due to serious medical adverse effects including paralysis, cortical blindness, and death. The inhalation form of triamcinolone is not indicated for use in acute asthma. Additionally, prolonged use of glucocorticoids may lead to hypothalamic-pituitary-adrenal (HPA) suppression. In patients with head trauma, high doses of corticosteroids are not recommended due to the risk of early mortality. Systemic corticosteroids are not indicated for use in fungal or viral infections. Contraindications to triamcinolone include patients with tuberculosis due to the risk of reactivation. 

Patients diagnosed with diabetes mellitus are advised to use caution when taking triamcinolone due to its hyperglycemic adverse effect. A higher incidence of skin atrophy is noted with glucocorticoid use in the elderly population due to aging. Patients diagnosed with psychosis are advised to use extreme caution as triamcinolone may cause exacerbation of related symptoms.

Corticosteroids are known to exacerbate glaucoma; thus, primary care physician supervision is necessary. Pregnant patients are not recommended to use triamcinolone for prolonged use due to potency. Corticosteroid use is contraindicated in children under the age of two.[12][13]

Monitoring

Patients taking triamcinolone should undergo monitoring for the relief of symptoms and any adverse effects. The liver (LFTs) and kidney (BUN and creatinine concentrations) function also require monitoring in individuals with hepatic or renal impairment, and dose adjustment made accordingly. It is essential to monitor the cardiac function in patients with a past medical history of congestive heart failure or arrhythmias. 

Triamcinolone storage should be in a cool, dry area at room temperature (between 68 to 77 degrees F).[14][15]

Toxicity

Glucocorticoids such as triamcinolone can cause variable neuropsychiatric symptoms to develop. Examples of these symptoms include mania, depression, delirium, and psychosis. These symptoms and other cognitive issues as a result of taking triamcinolone can be reversible after discontinuing the medication. Researchers have noted an increased risk of suicide in patients on chronic glucocorticoid therapy, so its use warrants caution. Cardiovascular effects can also be seen in patients using triamcinolone. Premature atherosclerosis, hypertension, fluid retention, and arrhythmias can occur in these patients, especially when prescribing a higher dosage of the drug. Many of these cardiovascular issues are likely to disappear upon discontinuation of triamcinolone.[16][17][18]

Enhancing Healthcare Team Outcomes

Managing the administration of triamcinolone requires an interdisciplinary team consisting of a primary care physician, pharmacist, nurse, and other specialty physicians such as an allergist or dermatologist. An immunologist should also evaluate immune system processes affected by the administration of triamcinolone. The healthcare team must instruct patients as to what the proper technique for applying triamcinolone is. The healthcare team should be considerate of adverse effects as well as therapeutic outcomes of triamcinolone. Nursing can verify patient compliance, answer questions, provide counsel, and monitor for adverse events and treatment effectiveness, informing the clinician of any concerns that may arise. Pharmacists should have involvement for recommendations regarding dosing and storage. Additionally, A clinical pharmacologist consult is necessary if the patient is experiencing toxicity symptoms. Regular follow up with the patient is prudent to assess for abnormalities and drug efficacy.

To summarize, triamcinolone therapy requires an interprofessional team approach, including physicians, specialists, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level V]


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Triamcinolone - Questions

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A 16-year-old male, known asthmatic, comes to the clinic for a follow-up visit. The patient presents with chest tightness and wheezing during breathing and a cough that is worse during exertion. Upon further inquiry, the patient reveals that he uses his albuterol inhaler more than twice a week during the day and less than once a week during the night for symptom control. Which of the following is the next best step in the management of this patient?



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A 55-year-old female patient comes to the clinic complaining of fatigue and left knee swelling and stiffness for the past 5 days. The patient has a past medical history of rheumatoid arthritis and hypertension. The patient reports she is currently on ibuprofen 800 mg three times a day and lisinopril 10 mg a day. On examination of the left knee, you note redness with swelling of the area and a limited range of motion with flexion and extension of the knee. What is the next step in management for this patient?



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A 16-year-old girl presents to the clinic with itchiness, redness, and dry skin on both her forearms and behind her knees for the past month. The patient states she has tried various moisturizing creams with minimal relief. After examination, she is diagnosed with atopic dermatitis. Which of the following is the next best step in the management of this patient?



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A 12-year-old male with a history of asthma presents to the clinic with his mother complaining of shortness of breath and wheezing for the past 6 months. As per the mother, the patient is currently on an albuterol inhaler which provides some symptomatic relief. Upon examination of the lungs, diffuse wheezes are heard on exhalation in all lung fields. Which of the following is the next best step in the management of this patient?



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A 10-year-old male presents to the clinic with his father complaining of itchiness, runny nose, and watery eyes for the past two weeks. The father reports the symptoms are worse during the pollen season. The child was given cetirizine, which provided some relief but made the child sleepy during the daytime. Allergic rhinitis is suspected. Which of the following is the next best step in the management of this patient?



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A 16-year-old girl presents to the clinic with red, itchy bumps on her right lower leg. Upon further questioning, the patient reports she was hiking this past weekend and scratched her leg against a plant while tripping on a tree branch. Physical examination shows an erythematous papular rash with surrounding edema on the right lower leg above the ankle. Which of the following is the next best step in the management of this patient?



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Triamcinolone - References

References

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Karangizi AHK,Al-Shaghana M,Logan S,Criseno S,Webster R,Boelaert K,Hewins P,Harper L, Glucocorticoid induced adrenal insufficiency is common in steroid treated glomerular diseases - proposed strategy for screening and management. BMC nephrology. 2019 May 6;     [PubMed]
Vestbo J,Vogelmeier CF,Small M,Siddall J,Fogel R,Kostikas K, Inhaled corticosteroid use by exacerbations and eosinophils: a real-world COPD population. International journal of chronic obstructive pulmonary disease. 2019;     [PubMed]
Luís M,Freitas J,Costa F,Buttgereit F,Boers M,Jap DS,Santiago T, An updated review of glucocorticoid-related adverse events in patients with rheumatoid arthritis. Expert opinion on drug safety. 2019 May 6;     [PubMed]
Santiago T,da Silva JA, Safety of low- to medium-dose glucocorticoid treatment in rheumatoid arthritis: myths and reality over the years. Annals of the New York Academy of Sciences. 2014 May;     [PubMed]
Scheun J,Greeff D,Ganswindt A, Non-invasive monitoring of glucocorticoid metabolite concentrations in urine and faeces of the Sungazer ({i}Smaug giganteus{/i}). PeerJ. 2018;     [PubMed]

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