Introduction
Kenalog (triamcinolone acetonide) is a synthetic glucocorticoid corticosteroid available in various formulations including injectable suspensions, topical creams, ointments, lotions, and oral inhalers. As an intermediate-acting corticosteroid, it provides potent anti-inflammatory and immunosuppressive effects for managing various inflammatory and allergic conditions.
Mechanism of Action
Triamcinolone acetonide binds to specific cytoplasmic glucocorticoid receptors, forming a complex that translocates to the cell nucleus. This complex binds to glucocorticoid response elements on DNA, resulting in:
- Modulation of gene transcription
- Inhibition of inflammatory cytokine production
- Decreased migration of inflammatory cells to sites of inflammation
- Stabilization of lysosomal membranes
- Reduction in capillary permeability
The drug's anti-inflammatory potency is approximately 8 times that of hydrocortisone.
Indications
FDA-approved indications:- Intra-articular injection: Rheumatoid arthritis, osteoarthritis
- Intramuscular injection: Endocrine disorders, rheumatic disorders, collagen diseases, dermatologic diseases, allergic states, ophthalmic diseases, respiratory diseases, hematologic disorders, neoplastic diseases, edematous states, gastrointestinal diseases
- Topical formulations: Inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses
- Oral inhalation: Bronchial asthma and related conditions
- Keloid and hypertrophic scar treatment
- Alopecia areata
- Lichen planus
- Psoriasis
- Oral lichen planus (topical)
- Chondritis of the ear
Dosage and Administration
Injectable formulations:- Intra-articular: 2.5-40 mg depending on joint size (typically 10-40 mg for large joints)
- Intramuscular: 40-80 mg initially, repeated at intervals
- Intralesional: 2.3-40 mg depending on lesion size and location
- Apply thin film to affected area 2-4 times daily
- Hepatic impairment: Use with caution; may require dose adjustment
- Renal impairment: Use with caution
- Pediatrics: Use lowest effective dose; monitor growth
- Elderly: Increased risk of adverse effects; consider lower doses
Pharmacokinetics
Absorption: Variable depending on formulation and route:- Injectable: Systemic absorption occurs with all routes
- Topical: Minimal systemic absorption with intact skin; increased with broken skin
- Oral inhalation: Approximately 20% reaches systemic circulation
Contraindications
- Hypersensitivity to triamcinolone acetonide or any component
- Systemic fungal infections
- Idiopathic thrombocytopenic purpura (IM administration)
- Live virus vaccinations during immunosuppressive therapy
- Active untreated infections at injection site (for local administration)
Warnings and Precautions
Black Box Warning: Corticosteroids can cause serious and fatal infections due to immunosuppression- Increased susceptibility to infections
- May mask signs of infection
- Adrenal suppression with prolonged use
- Ophthalmic effects: Cataracts, glaucoma
- Psychiatric effects: Euphoria, insomnia, mood swings, depression
- Glucose intolerance and diabetes mellitus
- Osteoporosis and avascular necrosis
- Growth suppression in children
- Kaposi's sarcoma with topical use
Drug Interactions
Significant interactions:- CYP3A4 inhibitors (ketoconazole, itraconazole): Increased corticosteroid levels
- CYP3A4 inducers (rifampin, phenytoin): Decreased corticosteroid levels
- Anticoagulants: Altered response
- Diuretics: Enhanced potassium excretion
- NSAIDs: Increased GI ulcer risk
- Vaccines: Diminished antibody response
- Diabetes medications: Altered glycemic control
Adverse Effects
Common:- Injection site reactions (pain, atrophy, hypopigmentation)
- Fluid retention
- Weight gain
- Hypertension
- Mood changes
- Insomnia
- Hyperglycemia
- Anaphylaxis
- Severe infections
- Adrenal insufficiency
- Osteonecrosis
- Peptic ulcer disease
- Psychosis
- Severe hyperglycemia
- Vision changes
Monitoring Parameters
- Blood pressure at each visit
- Weight regularly
- Blood glucose monitoring, especially in diabetics
- Electrolytes (potassium) with prolonged therapy
- Bone density with long-term use
- Growth velocity in children
- Ophthalmic exams with prolonged use
- Signs/symptoms of infection
- Adrenal function tests if indicated
Patient Education
- Use exactly as prescribed; do not stop abruptly
- Report any signs of infection (fever, sore throat)
- Inform all healthcare providers about Kenalog use
- Monitor for weight gain, swelling, mood changes
- Diabetic patients should monitor blood sugar closely
- Avoid exposure to infections when possible
- Report vision changes promptly
- Use sun protection as drug may increase photosensitivity
- For injectable forms: Report any pain, redness, or swelling at injection site
- Do not receive live vaccines while on therapy
References
1. Lexicomp Online. Triamcinolone acetonide monograph. Wolters Kluwer Clinical Drug Information, Inc. 2023. 2. Joint Formulary Committee. British National Formulary. London: BMJ Group and Pharmaceutical Press. 2023. 3. Curtis JR, Westfall AO, Allison J, et al. Population-based assessment of adverse events associated with long-term glucocorticoid use. Arthritis Rheum. 2006;55(3):420-426. 4. Liu D, Ahmet A, Ward L, et al. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy Asthma Clin Immunol. 2013;9(1):30. 5. Pfizer Laboratories. Kenalog package insert. New York, NY: Pfizer Inc. 2022. 6. Barnes PJ. Glucocorticosteroids. In: Brunton LL, Hilal-Dandan R, Knollmann BC, eds. Goodman & Gilman's: The Pharmacological Basis of Therapeutics. 13th ed. New York, NY: McGraw-Hill; 2018.