Triamcinolone acetonide ia / im inj 40mg/ml
- Drugs List
- Therapeutic Indications
- Dosage
- Administration
- Contraindications
- Precautions and Warnings
- Pregnancy and Lactation
- Side Effects
- Monograph
Presentation
Injections of triamcinolone acetonide.
Drugs List
Therapeutic Indications
Uses
Adrenal insufficiency - cortical
Pain in joint
Palliative treatment of neoplastic disease
Suppression of inflammatory & allergic conditions
Intra-articular administration:
Tenosynovitis
Bursitis
Epicondylitis
Alleviating joint pain, swelling and stiffness associated with rheumatoid arthritis and osteoarthrosis with an inflammatory component.
Intra-muscular administration:
Where sustained systemic corticosteroid treatment is required:
Allergic states such as bronchial asthma, seasonal or perennial rhinitis,
Endocrine disorders (For example, primary or secondary adrenocortical insufficiency)
Collagen disease (for example, during an exacerbation of maintenance therapy in selected cases of systemic lupus erythematosus or acute rheumatic carditis)
Dermatological disorders such as pemphigus, severe dermatitis and Stevens-Johnson syndrome
Gastro-intestinal disorders (short term adjunctive treatment)
Respiratory disorders (short term adjunctive treatment)
Rheumatic disorders (short term adjunctive treatment)
Haematological disorders such as acquired (autoimmune) haemolytic anaemia
Neoplastic diseases (such as palliative management of leukaemia and lymphomas)
Renal disease (for example, acute interstitial nephritis, minimal change nephrotic syndrome or lupus nephritis)
Dosage
Adults
Intra-muscular injection
Initial dose: 40mg injected deeply into the upper, outer quadrant of the gluteal muscle. Repeat if required.
Maximum dose: 100mg for injection.
Patients with hay fever or pollen asthma who do not respond to conventional therapy may obtain a remission of symptoms lasting throughout the pollen season after a single dose of 40mg to 100mg given when allergic symptoms appear.
Intra-articular, tendon sheath or intrabursal injection
Smaller joints: 5mg to 10mg depending on the specific disease being treated.
Larger joints: Up to 40mg depending on the specific disease being treated.
Subsequent dosage depends on the patient's response and period of relief and should be given when symptoms recur and not at set intervals.
Single injections into several sites for multiple joint involvement, up to a total of 80mg, have been given without undue reactions.
It has been recommended that, when injections are given into the sheaths of short tendons, a preparation containing triamcinolone acetonide 10mg/ml should be used.
Children
Intra-muscular injection
Children aged over 12 years
(See Dosage: Adult)
Children aged 6 to 12 years
Initial dose: 40mg (injected deeply into the upper, outer quadrant of the gluteal muscle) titrated to the severity of the symptoms and the age and weight of the child.
Intra-articular injection (unlicensed for under 6 years)
Children aged 1 to 18 years
2mg/kg (up to a usual maximum of 40mg).
Additional Dosage Information
Triamcinolone withdrawal
Treatment should not be withdrawn abruptly from patients who have received more than one intramuscular injection during a three week period (i.e. more than physiological doses). The dose should be reduced and the dosage interval increased until a dose of not more than 40mg and a dosage interval of at least three weeks have been achieved as the dose of systemic corticosteroid is reduced.
Abrupt withdrawal of short term systemic corticosteroid treatment is appropriate if it is considered that the disease is unlikely to relapse. A single dose, which is not repeated within a three week period, is unlikely to lead to clinically relevant hpa-axis suppression in the majority of patients. However, gradual withdrawal of systemic corticosteroid therapy should always be considered in:
-Patients who have had repeated courses of systemic corticosteroids
-When a course of triamcinolone has been prescribed within one year of cessation of long term therapy (months or years)
-Patients who may have reasons for adrenocortical insufficiency other than exogenous corticosteroid therapy
Administration
For intra-articular or deep intramuscular injection (into the gluteal site) only.
Contraindications
Children under 1 year
Injection into the Achilles tendon
Uncontrolled systemic infection
Injection into septic arthritic joints
Precautions and Warnings
Children under 6 years
Elderly
Exanthematous disorder
Family history of glaucoma
Acute glomerulonephritis
Breastfeeding
Congestive cardiac failure
Diabetes mellitus
Diverticulitis
Epileptic disorder
Gastrointestinal anastomosis
Glaucoma
Hepatic cirrhosis
Hepatic impairment
History of severe affective disorders
History of steroid myopathy
History of steroid-induced psychosis
Hypertension
Hyperthyroidism
Hypothyroidism
Latent or healed tuberculosis
Metastatic carcinoma
Myasthenia gravis
Nephritis
Osteoporosis
Peptic ulcer
Pregnancy
Renal impairment
Thrombophlebitis
Administration of live vaccines is not recommended
May mask symptoms or signs of infections
Exclude joint infection before injection
Not all routes are licensed for all age groups
Not all routes are licensed for all indications
Contains benzyl alcohol
Do not inject into unstable joints
With tendon sheath injections avoid injecting into the tendon
Prolonged or high dose may lead to adrenal suppression
Psychological changes may occur during initiation & withdrawal of treatment
Supervise patient closely during drug withdrawal
Adrenal cortical atrophy may persist for years after stopping drug
Advise patient to report any blurred vision or any other eye symptoms
Antibody response to vaccines may be reduced
Corticosteroids may cause growth retardation in children under 18 years
Discontinue if psychiatric disturbances develop
May cause anaphylactic / anaphylactoid reactions
Post menopausal women may experience vaginal bleeding
Sudden withdrawal may be inadvisable -see product information/SPC
Maintain treatment at the lowest effective dose
Avoid prolonged use
Advise patient not to take NSAIDs unless advised by clinician
Advise patient not to take St John's wort concurrently
Advise patient not to overuse joints even if symptomatic benefit is felt
Advise patient that menstrual irregularities may occur
Advise patient to rest treated joint after intra-articular injection
Advise patient to seek urgent medical attention if exposed to measles
Advise those on systemic corticosteroids to avoid chickenpox/H zoster
Consider issuing Steroid Treatment/Steroid Emergency Card
If exposed to chickenpox or Herpes zoster seek urgent medical attention
Patients on prolonged therapy require liberal protein intake
Patients (or parents of children) without a definite history of chicken pox should be advised to avoid close personal contact with chicken pox or herpes zoster and seek urgent medical attention if exposed as chicken pox can prove fatal in immunocompromised patients. If exposed while on triamcinolone acetonide or within three months of previous use, passive immunisation with varicella/zoster immunoglobulin (VZIG) should be administered within 10 days of the exposure. If chicken pox occurs, treat urgently under specialist care. Do not stop triamcinolone acetonide therapy, an upward dosage adjustment may be required.
Consider referring patients to an ophthalmologist for evaluation if they present with symptoms such as blurred vision or other visual disturbances. Possible causes may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy (CSCR) which have been reported after use of systemic and topical corticosteroids.
Pregnancy and Lactation
Pregnancy
Use triamcinolone acetonide with caution during pregnancy.
The manufacturer advises that triamcinolone should only be used when the benefits to the mother and child outweigh the risks. Administration of corticosteroids to pregnant women may increase the risk of intra-uterine growth retardation. Animal studies have shown foetal development abnormalities. At the time of writing, there is limited published information regarding the use of triamcinolone acetonide during human pregnancy. Triamcinolone crosses the placental barrier.
Lactation
Use triamcinolone acetonide with caution during breastfeeding.
The manufacturer advises that corticosteroids may pass into breast milk. At the time of writing, there is limited published information concerning the use of triamcinolone during breastfeeding. Infants of mothers taking high doses of systemic corticosteroids for prolonged periods may have a degree of adrenal suppression. 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.
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
Abscess (sterile)
Aggravation of pre-existing psychiatric conditions
Amnesia
Anxiety
Behavioural disturbances
Blurred vision
Candidiasis (gastro-intestinal)
Cardiac arrhythmias
Charcot-like arthropathy
Confusion
Congestive cardiac failure
Convulsions
Corneal thinning
Cushingoid changes
Cutaneous atrophy
Depression
Dermatological disturbances
Dizziness
Dyspepsia
Ecchymosis
Endocrine disturbances
Euphoria
Exacerbation of ophthalmic fungal disease
Exacerbation of ophthalmic viral disease
Exophthalmos
Facial erythema
Facial flushing (transient)
Fatigue
Fluid and electrolyte disturbances
Fractures
Gastro-intestinal symptoms
Glaucoma
Headache
Hirsutism
Hyperpigmentation
Hypersensitivity reactions
Hypertension
Hypokalaemic alkalosis
Hypopigmentation
Immunosuppression
Impaired carbohydrate tolerance, increased need for anti-diabetic therapy
Increased appetite
Increased calcium excretion
Increased intra-ocular pressure
Increased susceptibility and severity of infections
Increased sweating
Insomnia
Irritation (localised)
Joint discomfort
Leucocytosis
Lipoatrophy at injection site
Lupus erythematosus
Menstrual disturbances
Muscle weakness
Musculoskeletal disturbances
Myopathy
Necrotising angiitis
Neuritis
Neurological disorders
Ophthalmic disturbances
Osteonecrosis
Osteoporosis
Pancreatitis
Papilloedema
Peptic ulceration with perforation and haemorrhage
Petechiae
Post-injection flare
Posterior subcapsular cataracts
Psychiatric disorders
Psychotic reactions
Purpura
Raised intracranial pressure
Rare instances of blindness with intralesional therapy around face and head
Recurrence of dormant tuberculosis
Scleral thinning
Secondary adrenocortical and pituitary unresponsiveness
Sleep disturbances
Striae
Subcutaneous atrophy
Suppression of clinical signs of infection
Suppression of the hypothalamic-pituitary-adrenal axis
Syncope
Tendon rupture
Thromboembolism
Thrombophlebitis
Transient pain and swelling
Ulcerative oesophagitis
Vertigo
Weight gain
Withdrawal symptoms
Wound healing retarded
Withdrawal Symptoms and Signs
Too rapid a reduction of corticosteroid dosage following prolonged treatment can lead to acute adrenal insufficiency, hypotension and death. A 'withdrawal syndrome' may also occur including fever, myalgia, arthralgia, rhinitis, conjunctivitis, painful itchy skin nodules and weight loss.
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 ).
Further Information
Last Full Review Date: March 2020
Reference Sources
Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 3rd edition (2015) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.
Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 10th edition (2015) ed. Briggs, G., Freeman, R. Wolters Kluwer Health, Philadelphia.
Summary of Product Characteristics: Kenalog Intra-articular / Intramuscular Injection. E.R. Squibb and Sons Limited. May 2020.
NICE Evidence Services Available at: www.nice.org.uk Last accessed: 22 November 2019
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: 31 October 2018
Last accessed: 22 November 2019
Medscape UK | Univadis prescription drug monographs & interactions are based on FDB Multilex Content
FDB Disclaimer : FDB Multilex is intended for the use of healthcare professionals and is provided on the basis that the healthcare professionals will retain FULL and SOLE responsibility for deciding what treatment to prescribe or dispense for any particular patient or circumstance.