Triamcinolone (Kenalog)

1. Health Canada Product Monograph — Triamcinolone

• Triamcinolone injection is used for intramuscular systemic corticosteroid therapy in conditions such as severe dermatoses, rheumatoid arthritis, and other connective tissue disorders.
• It is used adjunctively for allergic conditions, including hay fever and pollen-induced asthma, when conventional therapy has not controlled symptoms.
• It is injected directly into joints, bursae, or tendon sheaths for short-term relief of synovitis, bursitis, gouty arthritis, epicondylitis, tenosynovitis, and osteoarthritis flares.
• It is injected into the skin (intradermally) for localized conditions such as keloids, discoid lupus erythematosus, alopecia areata, psoriatic plaques, lichen planus, and other resistant inflammatory skin lesions.

• Triamcinolone has not been adequately studied in pregnant women, so it should be used in pregnancy only if the potential benefit justifies the potential risk to the fetus.
• Some corticosteroids have shown teratogenic effects in animal studies, and infants born to mothers who received substantial doses of triamcinolone during pregnancy should be monitored for signs of adrenal suppression.

• Triamcinolone and other corticosteroids can pass into breast milk, so a decision should be made between stopping breastfeeding and stopping the medication based on the importance of treatment to the mother.

• Older adults are more likely to experience serious consequences from common corticosteroid side effects such as osteoporosis and high blood pressure, so close clinical supervision is recommended.

• Triamcinolone injection is not recommended for children under 6 years of age and must not be used in newborn or premature infants because the formulation contains benzyl alcohol.
• Corticosteroids can suppress growth in children on prolonged therapy, so growth and development should be monitored closely during treatment.

• For systemic (intramuscular) therapy in adults and children over 12, the usual starting dose is 60 mg injected deeply into the gluteal muscle, with maintenance doses typically adjusted between 40 and 80 mg depending on response; some patients are controlled on 20 mg or less.
• For hay fever or pollen-induced asthma unresponsive to conventional treatment, a single injection of 40 to 100 mg may provide relief for an entire pollen season.
• For children 6 to 12 years, the suggested initial systemic dose is 40 mg, adjusted according to symptom severity rather than age or weight alone.
• For intra-articular or intrabursal injection, the initial dose ranges from 2.5 to 5 mg for smaller joints and 5 to 15 mg for larger joints, with adults sometimes receiving up to 10 mg in small areas or 40 mg in large areas.
• For intradermal (intralesional) injection into skin lesions, doses are limited to about 1 mg per injection site to reduce the risk of skin thinning, using multiple sites spaced at least 1 cm apart if needed.
• Dosing must be individualized to the lowest amount that controls the condition, with gradual tapering after long-term use to avoid adrenal insufficiency.

If overdose is suspected, seek emergency medical attention immediately or contact your regional Poison Control Centre without delay.

• Chronic excessive use of triamcinolone may cause confusion, anxiety, depression, stomach cramping or bleeding, bruising, a rounded "moon" face, and high blood pressure.
• Rapid withdrawal after long-term high-dose use can trigger acute adrenal insufficiency, particularly during times of physical stress.
• Continued use of large doses can produce Cushingoid changes such as fat redistribution and skin thinning.
• There is no specific antidote for acute overdose; management is supportive, and any gastrointestinal bleeding is treated as it arises.

• Pain and irritation at the injection site may occur.
• Joint pain may occur, particularly after intra-articular injection.
• Fatigue may occur.
• Skin rash may occur.
• Changes in skin colour (darker or lighter patches) may occur at the injection site.
• Increased sweating may occur.
• Acne may occur.
• Bloating may occur.
• Dizziness or vertigo may occur.
• Headache may occur.
• Trouble sleeping (insomnia) may occur.

Serious side effects require immediate discussion with the prescriber or emergency care.

• Wasting of tissue (atrophy) and skin thinning at the injection site may occur, especially with repeated or improperly placed injections.
• Serious allergic reactions, including anaphylaxis and anaphylactic shock, have been reported and can be fatal.
• Mental health changes such as mood swings, depression, or behavioural changes may occur.
• Masking or worsening of infections can occur because triamcinolone suppresses the immune response.
• Menstrual irregularities, including postmenopausal vaginal bleeding, may occur.
• Muscle weakness and loss of muscle mass (myopathy) may develop with prolonged use.
• Osteoporosis and an increased risk of fractures, including of the spine, can occur with long-term therapy.
• Peptic ulcer disease, with possible bleeding or perforation, may develop.
• Seizures have been reported.
• Electrolyte imbalances, including low potassium, may cause weakness, muscle cramps, or an irregular heartbeat.
• Eye problems, including cataracts, glaucoma, blurred vision, or vision loss, may occur, particularly with prolonged use.
• Heart problems such as high blood pressure, fainting, or an irregular heartbeat may occur.
• High blood sugar or worsening of diabetes may occur.
• Inflammation of the pancreas (pancreatitis) may occur, presenting as upper abdominal pain with nausea and vomiting.
• Blood clots (thromboembolism) or vein inflammation (thrombophlebitis) may occur.
• Seek immediate medical attention for signs of severe allergic reaction, seizures, severe abdominal pain, chest pain, or a very slow or irregular heartbeat.

• Use with caution in patients with active or latent peptic ulcer disease, diverticulitis, or recent bowel surgery, due to the risk of bleeding or perforation.
• Use with caution in patients with kidney disease, high blood pressure, or congestive heart failure, since triamcinolone can cause salt and fluid retention.
• Use with caution in patients with osteoporosis or other conditions predisposing to bone loss.
• Use with caution in patients with diabetes, as blood sugar control may worsen.
• Use with caution in patients with a history of mental health conditions, including depression or psychosis.
• Use with caution in patients with myasthenia gravis or seizure disorders.
• Use with caution in patients with an underactive or overactive thyroid or with liver disease, as these can alter the drug's effects.
• Use with caution in patients undergoing surgery, since the body's stress response may need supplemental steroid coverage.
• Use with caution in patients exposed to chickenpox, measles, or shingles, since corticosteroids increase the severity of these infections.

• Contraindicated in patients with known hypersensitivity to triamcinolone or to any ingredient in the formulation.
• Contraindicated in patients with a systemic infection.
• Contraindicated in patients with idiopathic thrombocytopenic purpura when given intramuscularly.
• Contraindicated for intravenous, epidural, or intrathecal injection, since this formulation is a suspension not intended for those routes.

• Combining triamcinolone with other potassium-depleting drugs, such as amphotericin B, increases the risk of low blood potassium.
• Triamcinolone may reduce the effect of anticholinesterase medications.
• Triamcinolone may increase or decrease the effect of oral anticoagulants, so clotting status should be monitored closely.
• Triamcinolone can raise blood sugar and reduce the effectiveness of diabetes medications, requiring closer glucose monitoring.
• Triamcinolone may lower blood levels of the antibiotic isoniazid.
• Combined use with cyclosporine can increase the activity of both drugs.
• Strong CYP3A4 inhibitors, such as ketoconazole, itraconazole, clarithromycin, ritonavir, and grapefruit juice, can raise triamcinolone levels and increase the risk of corticosteroid side effects such as Cushing's syndrome and adrenal suppression.
• Triamcinolone combined with digitalis medications can increase the risk of digitalis toxicity.
• Estrogen-containing medications, including oral contraceptives, can increase triamcinolone blood levels.
• Enzyme-inducing medications such as barbiturates, phenytoin, carbamazepine, and rifampin can reduce triamcinolone's effectiveness by speeding its clearance.
• Triamcinolone may reduce the growth-promoting effect of human growth hormone.
• Triamcinolone may alter the effect of muscle relaxants used during anesthesia.
• Combining triamcinolone with NSAIDs increases the risk of stomach bleeding and ulcers.
• Vaccination during triamcinolone therapy may result in a reduced immune response or, with live vaccines, neurological complications.

• Triamcinolone is given by injection, so there are no food-related timing restrictions to observe.

• Triamcinolone injections are given by a trained healthcare professional in a clinic setting; there is no specific time-of-day requirement, and food intake is not a factor since the drug is not taken by mouth.

• Store triamcinolone injection at room temperature between 15°C and 30°C, protected from light, and do not freeze or refrigerate.
• Once a vial has been punctured, use it within 28 days when stored at 15°C to 25°C.

• Triamcinolone is a corticosteroid injection used to treat arthritis flares, severe allergic reactions, and certain inflammatory skin conditions.
• Tell your healthcare provider about any infections, stomach ulcers, diabetes, heart or kidney problems, mental health history, or upcoming surgery before receiving triamcinolone.
• Report any signs of infection, unusual mood changes, vision changes, or severe stomach pain to your healthcare provider promptly.
• Do not stop long-term triamcinolone therapy abruptly; your provider will guide any dose reduction to avoid adrenal insufficiency.
• Keep all follow-up appointments so your provider can monitor for corticosteroid-related side effects.