triamcinolone (systemic)
Aristocort, Aristopak, Kenacort

triamcinolone acetonide
Kenalog, Tac

triamcinolone diacetate
Amcort, Aristocort, Aristocort Forte, Aristocort Intralesional

triamcinolone hexacetonide
Aristospan Intra-articular, Aristospan Intralesional

Available forms
Available by prescription only
triamcinolone
Syrup: 4 mg/ml
Tablets: 4 mg, 8 mg
triamcinolone acetonide
Injection: 3 mg/ml, 10 mg/ml, 40 mg/ml suspension
triamcinolone diacetate
Injection: 25 mg/ml, 40 mg/ml suspension
triamcinolone hexacetonide
Injection: 5 mg/ml, 20 mg/ml suspension

Indications and dosages
 Adrenal insufficiency. triamcinolone Adults: 4 to 12 mg P.O. daily, in single or divided doses.
Children: 117 mcg/kg or 3.3 mg/m² P.O. daily, in single or divided doses.
 Severe inflammation or immunosuppression. triamcinolone Adults: 8 to 16 mg P.O. daily, in single or divided doses.
Children: 416 mcg to 1.7 mg/kg or 12.5 to 50 mg/m² P.O. daily, in single or divided doses.
triamcinolone acetonide Adults: Initially, 60 mg I.M. Additional doses of 20 to 100 mg may be given, p.r.n., at 6-week intervals. Or, 2.5 to 15 mg intra-articularly, or up to 1 mg intralesionally, p.r.n.
Children ages 6 to 12: 0.03 to 0.2 mg/kg I.M. at 1- to 7-day intervals.
triamcinolone diacetate Adults: 40 mg I.M. once weekly. Or, 2 to 40 mg intra-articularly, intrasynovially, or intralesionally q 1 to 8 weeks. Or, 4 to 48 mg P.O., divided into four doses.
Children: 0.117 to 1.66 mg/kg/day P.O., divided into four doses.
triamcinolone hexacetonide Adults: 2 to 20 mg intra-articularly q 3 to 4 weeks, p.r.n. Or, up to 0.5 mg intralesionally per square inch of skin.
 Systemic lupus erythematosus. triamcinolone. Adults: 20 to 32 mg P.O. daily.
 Acute rheumatic carditis. triamcinolone. Adults: 20 to 60 mg P.O. daily.
 Tuberculous meningitis. triamcinolone. Adults: 32 to 48 mg P.O. daily.
 Edematous states. triamcinolone. Adults: 16 to 48 mg P.O. daily.
 Collagen diseases. triamcinolone. Adults: 30 to 48 mg P.O. daily.
 Dermatologic disorders. triamcinolone. Adults: 8 to 16 mg P.O. daily.
 Allergic states. triamcinolone. Adults: 8 to 12 mg P.O. daily.
 Ophthalmic diseases. triamcinolone. Adults: 12 to 40 mg P.O. daily.
 Respiratory diseases. triamcinolone. Adults: 16 to 48 mg P.O. daily.
 Hematologic diseases. triamcinolone. Adults: 16 to 60 mg P.O. daily.
 Neoplastic diseases. triamcinolone. Adults: 16 to 100 mg P.O. daily.

Pharmacodynamics
Anti-inflammatory action: Triamcinolone stimulates the synthesis of enzymes needed to decrease the inflammatory response. It suppresses the immune system by reducing activity and volume of the lymphatic system, producing lymphocytopenia (primarily of T lymphocytes), decreasing immunoglobulin and complement levels, decreasing passage of immune complexes through basement membranes, and possibly depressing reactivity of tissue to antigen-antibody interactions.
 Triamcinolone is an intermediate-acting glucocorticoid. The addition of a fluorine group in the molecule increases the anti-inflammatory activity, which is five times more potent than an equal weight of hydrocortisone. It has essentially no mineralocorticoid activity.
 Triamcinolone may be administered orally. The diacetate and acetonide salts may be administered by I.M., intra-articular, intrasynovial, intralesional, sublesional, and soft-tissue injection. The diacetate suspension is slightly soluble, providing a prompt onset of action and a longer duration of effect (1 to 2 weeks). Triamcinolone acetonide is relatively insoluble and slowly absorbed. Its extended duration of action lasts for several weeks. Triamcinolone hexacetonide is relatively insoluble, is absorbed slowly, and has a prolonged action of 3 to 4 weeks. Don’t administer any of the parenteral suspensions I.V.

Pharmacokinetics
Absorption: Absorbed readily after oral administration. After oral and I.V. administration, peak effects occur in about 1 to 2 hours. The suspensions for injection have variable onset and duration of action, depending on whether they’re injected into an intra-articular space or a muscle, and on the blood supply to that muscle.
Distribution: Removed rapidly from the blood and distributed to muscle, liver, skin, intestines, and kidneys. Drug is extensively bound to plasma proteins (transcortin and albumin). Only the unbound portion is active. Adrenocorticoids are distributed into breast milk and through the placental barrier.
Metabolism: Metabolized in the liver to inactive glucuronide and sulfate metabolites.
Excretion: The inactive metabolites and small amounts of unmetabolized drug are excreted by the kidneys. Insignificant quantities of drug are also excreted in feces. Biologic half-life of triamcinolone is 18 to 36 hours.

Contraindications and precautions
Contraindicated in patients hypersensitive to components of the formulations and in patients with systemic fungal infections.
  Use cautiously in patients with GI ulcer, renal disease, hypertension, osteoporosis, diabetes mellitus, hypothyroidism, cirrhosis, diverticulitis, nonspecific ulcerative colitis, recent intestinal anastomosis, thromboembolic disorders, seizures, myasthenia gravis, heart failure, hepatitis, tuberculosis, ocular herpes simplex, emotional instability, or psychotic tendencies.

Interactions
Drug-drug. Amphotericin B, diuretics: Enhances hypokalemia. Monitor patient closely.
Antacids, cholestyramine, colestipol: Decreases effect of triamcinolone. Dosage may need adjustment.
Barbiturates, phenytoin, rifampin: Decreases corticosteroid effects. Dosage may need adjustment.
Cardiac glycosides: Increases toxicity. Monitor patient closely.
Estrogens: Reduces metabolism of triamcinolone. Dosage may need adjustment.
Isoniazid, salicylates: Causes hyperglycemia. Dosage may need adjustment.
NSAIDs, ulcerogenic drugs: Increases risk of GI ulceration. Avoid use together.
Oral anticoagulants: Decreases anticoagulation. Monitor patient closely; dosage may need adjustment.

Adverse reactions
CNS: euphoria, insomnia, psychotic behavior, pseudotumor cerebri, vertigo, headache, paresthesia, seizures.
CV: heart failure, thromboembolism, hypertension, edema, arrhythmias, thrombophlebitis.
EENT: cataracts, glaucoma.
GI: peptic ulceration, GI irritation, increased appetite, pancreatitis, nausea, vomiting.
GU: menstrual irregularities, increased urine glucose and calcium levels.
Metabolic: hypokalemia, hyperglycemia, hypocalcemia, carbohydrate intolerance.
Musculoskeletal: muscle weakness, osteoporosis.
Skin: delayed wound healing, acne, various skin eruptions.
Other: cushingoid state (moonface, buffalo hump, central obesity), hirsutism, susceptibility to infections; growth suppression in children; acute adrenal insufficiency with increased stress (infection, surgery, or trauma) or abrupt withdrawal after long-term therapy.

Effects on lab test results
• May increase glucose and cholesterol levels. May decrease T₃, T₄, potassium, and calcium levels.

Overdose and treatment
Acute ingestion, even in massive doses, is rarely a clinical problem. Toxic signs and symptoms rarely occur if drug is used for less than 3 weeks, even at large doses. However, long-term use causes adverse physiologic effects, including suppression of the hypothalamic-pituitary-adrenal axis, cushingoid appearance, muscle weakness, and osteoporosis.

Special considerations
• Recommendations for use of triamcinolone and for care and teaching of patients during therapy are the same as those for all systemic adrenocorticoids.
 ALERT Gradually taper dosage. After abrupt withdrawal, patient may experience rebound inflammation, fatigue, weakness, arthralgia, fever, dizziness, lethargy, depression, fainting, orthostatic hypotension, dyspnea, anorexia, and hypoglycemia. After prolonged use, sudden withdrawal may be fatal.
• Most adverse reactions to corticosteroids are dose- or duration-dependent.
• Monitor patient for allergic reactions, adrenal insufficiency, and seizure activity.
• Monitor cardiac status.
• Triamcinolone suppresses reactions to skin tests; causes false-negative results in the nitroblue tetrazolium test for systemic bacterial infections; and decreases ¹³¹I uptake and protein-bound iodine levels in thyroid function tests.
Breast-feeding patients
• Use drug cautiously in breast-feeding women.
Pediatric patients
• Long-term use of drug in children and adolescents may delay growth and maturation.

Patient education
• Instruct patient to take drug exactly as prescribed and not to suddenly discontinue drug.
• Instruct patient to promptly report any adverse reactions or unusual symptoms.

Reactions may be common, uncommon, life-threatening, or COMMON AND LIFE THREATENING.
◆ Canada only
◇ Unlabeled clinical use