Drugs List

Therapeutic Indications

Uses

Intra-articular administration:
Tenosynovitis
Bursitis
Epicondylitis
Joint pain, swelling and stiffness associated with rheumatoid arthritis and osteoarthrosis with an inflammatory component.

Intradermal administration:
Lichen simplex chronicus (neuro-dermatitis)
Granuloma annulare
Lichen planus
Keloids
Alopecia areata
Hypertrophic scars

Administration

For intradermal or intra-articular injection using strict aseptic precautions.

Contraindications

Infections in the absence of anti-infective therapy
Children under 1 year
For administration by the intradermal or intra-articular routes only. Other routes of administration are contraindicated
Intra-articular injection should not be given into infected joints or where there is infection located near to joints.
Use in the achilles tendon (which lacks a true tendon sheath) is not recommended.

Precautions and Warnings

Intra-articular injection
Do not administer into unstable joints.
Take care that injections given into tendon sheaths are not injected into the tendon itself.
Avoid repeated injection into inflamed tendons as this may cause tendon rupture.

Warn patients not to overuse joints in which symptomatic benefit has been obtained.

Repeated intra-articular injections over a long period may lead to severe joint destruction with bone necrosis.

Not suitable for the relief of pain arising from infectious states such as gonococcal or tubercular arthritis.

Adequate studies to demonstrate the safety of use by intra-turbinal, subconjunctival, sub-tendons, retrobulbar and intraocular (intravitreal) injections have not been performed. 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.

General
To minimise undesirable effects, the lowest effective dose should be used for the minimum period of time, and by administering the daily requirement, whenever possible, as a single morning dose on alternate days. Review the patient's clinical condition frequently to titrate the dose appropriately against disease activity.

Adrenal cortical atrophy develops on prolonged treatment and may persist for years after treatment has ceased. After prolonged therapy, withdrawal should be gradual and tapered off over weeks or months according to the dose or duration of treatment.
During prolonged treatment, any additional stress such as intercurrent illness, trauma or surgical procedure will require a temporary increase in dose. If corticosteroids have been stopped after long term therapy, a temporary reintroduction may be required in such situations.

Patients should carry steroid cards which give clear guidance on the precautions to be taken to minimise risk.

Suppression of the inflammatory response and immune function increases the susceptibility to infections and their severity. Serious infections (such as septicaemia and tuberculosis) may be masked and reach an advanced stage before they are recognised.

Chicken pox and measles may follow a more serious course in patients receiving glucocorticosteroid. Particular care should be taken to avoid exposure in patients who have not previously had these diseases. If exposed the patient should seek urgent medical advice.

Passive immunisation with varicella-zoster immunoglobulin is needed for exposed non-immune patients receiving systemic corticosteroids or for those who have used them within the previous 3 months; varicella-zoster immunoglobulin should preferably be given within 3 days of exposure and not later than 10 days. Confirmed chicken pox warrants specialist care and urgent treatment. Corticosteroids should not be stopped and dosage may need to be increased.

Diabetes may be aggravated, necessitating a higher insulin dosage. Latent diabetes mellitus may be precipitated.

Menstrual irregularities may occur and female patients should be advised of the possibility.

Post menopausal women may experience vaginal bleeding.

Corticosteroid effects may be increased in hypothyroid patients or decreased in hyperthyroid patients.

Corticosteroid effects may be increased in patients with hepatic cirrhosis.

Anaphylactoid reactions may occur rarely and this is more likely in patients with a history of drug allergies.

Corticosteroids increase calcium excretion.

During corticosteroid therapy antibody response will be reduced and therefore affect the patients response to vaccines. Live vaccines should not be administered.

Patients should not self administer NSAID's unless under guidance from a clinician.

Particular care required in patients with existing or a history of severe affective disorders in themselves or in their first degree relatives.

Potentially severe psychiatric adverse reactions may occur, typically within a few days or weeks of starting treatment. Dose levels do not predict onset, type, severity or duration of reactions. most reactions recover after dose reduction or withdrawal, however specific treatment may be necessary. Patients/carers should be encouraged to seek medical advice if worrying psychological symptoms develop.

Corticosteroids may increase blood glucose; diabetic control should be monitored, especially when corticosteroids are initiated, discontinued, or a change in dosage.

Children under 6 years (see Dosage - Children ).
Monitor growth and development of children and adolescents on corticosteroid therapy as they cause dose-related growth retardation which may be irreversible.

This product contains 15mg/ml benzyl alcohol and must not be given to premature babies or neonates. Benzyl Alcohol may cause toxic reactions and anaphylactoid reactions in infants and children up to 3 years.

Elderly - use with caution as they are more susceptible to adverse effects.

Pregnancy (see Pregnancy ).

Breastfeeding (see Lactation ).

Use with caution in patients with the following conditions and monitor the patient frequently:
Recent intestinal anastomoses
Diverticulitis
Thrombophlebitis
Exanthematous disease
Existing or history or severe affective disorders (especially previous steroid psychosis)
Chronic nephritis
Renal insufficiency
Metastatic carcinoma
Osteoporosis (particularly post-menopausal females)
Active peptic ulcer or history of peptic ulcer
Myasthenia gravis
Latent or healed tuberculosis
Acute psychoses
Hypertension
Acute glomerulonephritis
Congestive heart failure
Glaucoma or family history of glaucoma
Previous steroid myopathy
Epilepsy
Liver failure
In presence of local or systemic viral infection
Systemic fungal infections
Active infections not controlled by antibiotics

Pregnancy and Lactation

Pregnancy

Contraindicated in pregnancy.

Administration of corticosteroids to pregnant women may increase the risk of intra-uterine growth retardation. At the time of writing, there is limited published experience concerning exposed pregnancies and their outcomes. Administration in animals has been reported to cause cause abnormalities of foetal development. Triamcinolone crosses the placental barrier but Schaefer (2007) concludes that inadvertent exposure to triamcinolone during the first trimester is not an indication for termination of the pregnancy or invasive diagnostics. Hypoadrenalism may, in theory, occur in the neonate following prenatal exposure to corticosteroids but usually resolves spontaneously following birth and is rarely clinically important.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14-17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Licensed in pregnancy? - No, Contraindicated

Recommended for use in pregnancy? - No

Known human teratogen? - Unknown

Animal data - Can cause abnormalities in foetal development

Crosses placenta? - Yes

Effects on foetus - May increase the risk of intra-uterine growth retardation

Lactation

Contraindicated in breastfeeding.

At the time of writing, there is no published experience concerning the use of triamcinolone during breastfeeding. Alternatives such as prednisolone and prednisone which are compatible with breastfeeding, are the corticosteroids of choice for systemic treatment during breastfeeding. If high doses of triamcinolone are repeatedly given then a 3-4 hour wait before breastfeeding may be preferred, however treatment is unlikely to result in large amounts in breast milk. Infants of mothers taking high doses of systemic corticosteroids for prolonged periods may have a degree of adrenal suppression (Schaefer, 2007).

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Drug excreted in breast milk? - Unknown

Considered suitable or recommended by manufacturer? - No

Drug substance licensed in infants? - No

Side Effects

Suppression of the hypothalamic-pituitary-adrenal axis
Immunosuppression
Increased susceptibility and severity of infections
Suppression of clinical signs of infection
Opportunistic infections
Recurrence of dormant tuberculosis
Fluid and electrolyte disturbances
Congestive cardiac failure
Cardiac arrhythmias
Hypokalaemic alkalosis
Increased calcium excretion
Hypertension
Musculoskeletal disturbances
Hypersensitivity reactions
Dermatological disturbances
Gastro-intestinal symptoms
Dyspepsia
Peptic ulceration with perforation and haemorrhage
Pancreatitis
Ulcerative oesophagitis
Candidiasis (gastro-intestinal)
Neurological disorders
Psychiatric disorders
Aggravation of pre-existing psychiatric conditions
Psychotic reactions
Behavioural disturbances
Endocrine disturbances
Secondary adrenocortical and pituitary unresponsiveness
Ophthalmic disturbances
Increased intra-ocular pressure
Necrotising angiitis
Thrombophlebitis
Thromboembolism
Leucocytosis
Insomnia
Syncope
Withdrawal symptoms
Facial flushing (transient)
Dizziness
Post-injection flare
Transient pain and swelling
Irritation (localised)
Abscess (sterile)
Hyperpigmentation
Hypopigmentation
Charcot-like arthropathy
Joint discomfort
Lipoatrophy at injection site
Cutaneous atrophy
Subcutaneous atrophy
Rare instances of blindness with intralesional therapy around face and head
Menstrual disturbances
Muscle weakness
Fatigue
Myopathy
Osteoporosis
Osteonecrosis
Fractures
Tendon rupture
Wound healing retarded
Petechiae
Ecchymosis
Facial erythema
Increased sweating
Purpura
Striae
Hirsutism
Lupus erythematosus
Euphoria
Depression
Convulsions
Vertigo
Headache
Neuritis
Anxiety
Sleep disturbances
Confusion
Amnesia
Weight gain
Increased appetite
Glaucoma
Exophthalmos
Papilloedema
Corneal thinning
Amenorrhoea
Postmenopausal bleeding

Presentation

Suspension for intra-articular or intradermal injection containing triamcinolone acetonide 10mg per ml.

Drugs List

Therapeutic Indications

Uses

Intra-articular administration:
Tenosynovitis
Bursitis
Epicondylitis
Joint pain, swelling and stiffness associated with rheumatoid arthritis and osteoarthrosis with an inflammatory component.

Intradermal administration:
Lichen simplex chronicus (neuro-dermatitis)
Granuloma annulare
Lichen planus
Keloids
Alopecia areata
Hypertrophic scars

Dosage

The lowest possible dose should be employed for the minimum period, in order to minimise adverse effects.

As the duration of effect is variable subsequent dosage depends on the patient's response and period of relief and should be given when symptoms recur and not at set intervals.

Adults

Elderly

Children

Additional Dosage Information

Administration

For intradermal or intra-articular injection using strict aseptic precautions.

Contraindications

Infections in the absence of anti-infective therapy
Children under 1 year
For administration by the intradermal or intra-articular routes only. Other routes of administration are contraindicated
Intra-articular injection should not be given into infected joints or where there is infection located near to joints.
Use in the achilles tendon (which lacks a true tendon sheath) is not recommended.

Precautions and Warnings

Intra-articular injection
Do not administer into unstable joints.
Take care that injections given into tendon sheaths are not injected into the tendon itself.
Avoid repeated injection into inflamed tendons as this may cause tendon rupture.

Warn patients not to overuse joints in which symptomatic benefit has been obtained.

Repeated intra-articular injections over a long period may lead to severe joint destruction with bone necrosis.

Not suitable for the relief of pain arising from infectious states such as gonococcal or tubercular arthritis.

Adequate studies to demonstrate the safety of use by intra-turbinal, subconjunctival, sub-tendons, retrobulbar and intraocular (intravitreal) injections have not been performed. 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.

General
To minimise undesirable effects, the lowest effective dose should be used for the minimum period of time, and by administering the daily requirement, whenever possible, as a single morning dose on alternate days. Review the patient's clinical condition frequently to titrate the dose appropriately against disease activity.

Adrenal cortical atrophy develops on prolonged treatment and may persist for years after treatment has ceased. After prolonged therapy, withdrawal should be gradual and tapered off over weeks or months according to the dose or duration of treatment.
During prolonged treatment, any additional stress such as intercurrent illness, trauma or surgical procedure will require a temporary increase in dose. If corticosteroids have been stopped after long term therapy, a temporary reintroduction may be required in such situations.

Patients should carry steroid cards which give clear guidance on the precautions to be taken to minimise risk.

Suppression of the inflammatory response and immune function increases the susceptibility to infections and their severity. Serious infections (such as septicaemia and tuberculosis) may be masked and reach an advanced stage before they are recognised.

Chicken pox and measles may follow a more serious course in patients receiving glucocorticosteroid. Particular care should be taken to avoid exposure in patients who have not previously had these diseases. If exposed the patient should seek urgent medical advice.

Passive immunisation with varicella-zoster immunoglobulin is needed for exposed non-immune patients receiving systemic corticosteroids or for those who have used them within the previous 3 months; varicella-zoster immunoglobulin should preferably be given within 3 days of exposure and not later than 10 days. Confirmed chicken pox warrants specialist care and urgent treatment. Corticosteroids should not be stopped and dosage may need to be increased.

Diabetes may be aggravated, necessitating a higher insulin dosage. Latent diabetes mellitus may be precipitated.

Menstrual irregularities may occur and female patients should be advised of the possibility.

Post menopausal women may experience vaginal bleeding.

Corticosteroid effects may be increased in hypothyroid patients or decreased in hyperthyroid patients.

Corticosteroid effects may be increased in patients with hepatic cirrhosis.

Anaphylactoid reactions may occur rarely and this is more likely in patients with a history of drug allergies.

Corticosteroids increase calcium excretion.

During corticosteroid therapy antibody response will be reduced and therefore affect the patients response to vaccines. Live vaccines should not be administered.

Patients should not self administer NSAID's unless under guidance from a clinician.

Particular care required in patients with existing or a history of severe affective disorders in themselves or in their first degree relatives.

Potentially severe psychiatric adverse reactions may occur, typically within a few days or weeks of starting treatment. Dose levels do not predict onset, type, severity or duration of reactions. most reactions recover after dose reduction or withdrawal, however specific treatment may be necessary. Patients/carers should be encouraged to seek medical advice if worrying psychological symptoms develop.

Corticosteroids may increase blood glucose; diabetic control should be monitored, especially when corticosteroids are initiated, discontinued, or a change in dosage.

Children under 6 years (see Dosage - Children ).
Monitor growth and development of children and adolescents on corticosteroid therapy as they cause dose-related growth retardation which may be irreversible.

This product contains 15mg/ml benzyl alcohol and must not be given to premature babies or neonates. Benzyl Alcohol may cause toxic reactions and anaphylactoid reactions in infants and children up to 3 years.

Elderly - use with caution as they are more susceptible to adverse effects.

Pregnancy (see Pregnancy ).

Breastfeeding (see Lactation ).

Use with caution in patients with the following conditions and monitor the patient frequently:
Recent intestinal anastomoses
Diverticulitis
Thrombophlebitis
Exanthematous disease
Existing or history or severe affective disorders (especially previous steroid psychosis)
Chronic nephritis
Renal insufficiency
Metastatic carcinoma
Osteoporosis (particularly post-menopausal females)
Active peptic ulcer or history of peptic ulcer
Myasthenia gravis
Latent or healed tuberculosis
Acute psychoses
Hypertension
Acute glomerulonephritis
Congestive heart failure
Glaucoma or family history of glaucoma
Previous steroid myopathy
Epilepsy
Liver failure
In presence of local or systemic viral infection
Systemic fungal infections
Active infections not controlled by antibiotics

Pregnancy and Lactation

Pregnancy

Contraindicated in pregnancy.

Administration of corticosteroids to pregnant women may increase the risk of intra-uterine growth retardation. At the time of writing, there is limited published experience concerning exposed pregnancies and their outcomes. Administration in animals has been reported to cause cause abnormalities of foetal development. Triamcinolone crosses the placental barrier but Schaefer (2007) concludes that inadvertent exposure to triamcinolone during the first trimester is not an indication for termination of the pregnancy or invasive diagnostics. Hypoadrenalism may, in theory, occur in the neonate following prenatal exposure to corticosteroids but usually resolves spontaneously following birth and is rarely clinically important.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14-17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Licensed in pregnancy? - No, Contraindicated

Recommended for use in pregnancy? - No

Known human teratogen? - Unknown

Animal data - Can cause abnormalities in foetal development

Crosses placenta? - Yes

Effects on foetus - May increase the risk of intra-uterine growth retardation

Lactation

Contraindicated in breastfeeding.

At the time of writing, there is no published experience concerning the use of triamcinolone during breastfeeding. Alternatives such as prednisolone and prednisone which are compatible with breastfeeding, are the corticosteroids of choice for systemic treatment during breastfeeding. If high doses of triamcinolone are repeatedly given then a 3-4 hour wait before breastfeeding may be preferred, however treatment is unlikely to result in large amounts in breast milk. Infants of mothers taking high doses of systemic corticosteroids for prolonged periods may have a degree of adrenal suppression (Schaefer, 2007).

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Drug excreted in breast milk? - Unknown

Considered suitable or recommended by manufacturer? - No

Drug substance licensed in infants? - No

Effects on Ability to Drive and Operate Machinery

None known.

Counselling

Advise patients not to overuse joints in which symptomatic benefit has been obtained.

Advise female patients that menstrual irregularities may occur.

Advise patients that they should carry steroid cards which give clear guidance on the precautions to be taken to minimise risk.

Advise patients to avoid exposure to chicken pox and measles in patients who have not previously had these diseases. If exposed the patient should seek urgent medical advice.

Advise patients should not self administer with NSAID's unless under guidance from a clinician.

Side Effects

Suppression of the hypothalamic-pituitary-adrenal axis
Immunosuppression
Increased susceptibility and severity of infections
Suppression of clinical signs of infection
Opportunistic infections
Recurrence of dormant tuberculosis
Fluid and electrolyte disturbances
Congestive cardiac failure
Cardiac arrhythmias
Hypokalaemic alkalosis
Increased calcium excretion
Hypertension
Musculoskeletal disturbances
Hypersensitivity reactions
Dermatological disturbances
Gastro-intestinal symptoms
Dyspepsia
Peptic ulceration with perforation and haemorrhage
Pancreatitis
Ulcerative oesophagitis
Candidiasis (gastro-intestinal)
Neurological disorders
Psychiatric disorders
Aggravation of pre-existing psychiatric conditions
Psychotic reactions
Behavioural disturbances
Endocrine disturbances
Secondary adrenocortical and pituitary unresponsiveness
Ophthalmic disturbances
Increased intra-ocular pressure
Necrotising angiitis
Thrombophlebitis
Thromboembolism
Leucocytosis
Insomnia
Syncope
Withdrawal symptoms
Facial flushing (transient)
Dizziness
Post-injection flare
Transient pain and swelling
Irritation (localised)
Abscess (sterile)
Hyperpigmentation
Hypopigmentation
Charcot-like arthropathy
Joint discomfort
Lipoatrophy at injection site
Cutaneous atrophy
Subcutaneous atrophy
Rare instances of blindness with intralesional therapy around face and head
Menstrual disturbances
Muscle weakness
Fatigue
Myopathy
Osteoporosis
Osteonecrosis
Fractures
Tendon rupture
Wound healing retarded
Petechiae
Ecchymosis
Facial erythema
Increased sweating
Purpura
Striae
Hirsutism
Lupus erythematosus
Euphoria
Depression
Convulsions
Vertigo
Headache
Neuritis
Anxiety
Sleep disturbances
Confusion
Amnesia
Weight gain
Increased appetite
Glaucoma
Exophthalmos
Papilloedema
Corneal thinning
Amenorrhoea
Postmenopausal bleeding

Withdrawal Symptoms and Signs

On withdrawal, the following effects may be seen:
Fever
Myalgia
Arthralgia
Rhinitis
Conjunctivitis
Painful itchy skin nodules
Weight loss

Rapid dose reduction after prolonged treatment may lead to acute adrenal insufficiency, hypotension and death.

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Shelf Life and Storage

Store in an upright position.
Do not store above 25 degrees C.
Do not freeze.

Further Information

Last Full Review Date: August 2012

Reference Sources

Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 2nd edition (2007) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 9th edition (2011) ed. Briggs, G., Freeman, R. and Yaffe, S. Lippincott Williams & Wilkins, Philadelphia.

Martindale: The Complete Drug Reference, 37th edition (2011) ed. Sweetman, S. Pharmaceutical Press, London.

Medications and Mothers' Milk, 14th Edition (2010) Hale, T. Hale Publishing, Amarillo, Texas.

Summary of Product Characteristics: Adcortyl Intra-articular/Intradermal Injection 10mg/ml. E. R. Squibb & Sons Limited. Revised March 2014.

NICE Evidence Services Available at: www.nice.org.uk Last accessed: 04 September 2017

US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Triamcinolone Last revised: July 10, 2012
Last accessed: August 10, 2012