Triamcinolone - Drug Monograph

Introduction

Triamcinolone is a synthetic glucocorticoid corticosteroid with potent anti-inflammatory and immunosuppressive properties. First approved by the FDA in the 1950s, it remains widely used across multiple formulations including oral, injectable, topical, and inhaled preparations. As an intermediate-acting corticosteroid, triamcinolone provides effective symptom control for various inflammatory and autoimmune conditions while maintaining a favorable therapeutic profile when used appropriately.

Mechanism of Action

Triamcinolone exerts its effects through binding to intracellular glucocorticoid receptors, forming a complex that translocates to the cell nucleus. This complex modulates gene transcription by binding to glucocorticoid response elements (GREs) in DNA, leading to:

• Inhibition of pro-inflammatory cytokine production (IL-1, IL-2, IL-6, TNF-α)
• Decreased synthesis of inflammatory mediators (prostaglandins, leukotrienes)
• Reduced migration of inflammatory cells to sites of inflammation
• Stabilization of lysosomal membranes
• Inhibition of fibroblast proliferation and collagen deposition

The drug's anti-inflammatory potency is approximately 5 times that of hydrocortisone, with minimal mineralocorticoid activity.

Indications

• Rheumatologic disorders (rheumatoid arthritis, osteoarthritis, bursitis)
• Dermatological conditions (psoriasis, eczema, contact dermatitis, lichen planus)
• Allergic conditions (allergic rhinitis, asthma, hypersensitivity reactions)
• Ophthalmic inflammation (uveitis, conjunctivitis, keratitis)
• Hematologic disorders (idiopathic thrombocytopenic purpura)
• Gastrointestinal diseases (ulcerative colitis, Crohn's disease)
• Neoplastic conditions (palliative management of leukemias and lymphomas)

• Alopecia areata
• Keloid management
• Oral lichen planus
• Sarcoidosis
• Thyroid eye disease

Dosage and Administration

• Oral tablets: 1mg, 2mg, 4mg, 8mg
• Injectable suspension: 3mg/mL, 10mg/mL, 40mg/mL
• Topical creams/ointments: 0.025%, 0.1%, 0.5%
• Dental paste: 0.1%
• Nasal spray: 55 mcg/spray
• Inhalation: 100 mcg/actuation

• Oral: Initial dose 4-48 mg/day in divided doses, tailored to condition severity
• Intra-articular: 2.5-40 mg depending on joint size
• Topical: Apply thin film to affected area 2-4 times daily
• Intranasal: 1-2 sprays per nostril once daily

• Hepatic impairment: Dose reduction required
• Renal impairment: Use with caution; monitor for adverse effects
• Elderly: Lower initial doses recommended
• Pediatrics: Dose based on body weight or surface area

Pharmacokinetics

Contraindications

• Systemic fungal infections
• Hypersensitivity to triamcinolone or any component
• Live virus vaccinations during immunosuppressive therapy
• Active untreated infections (unless concurrent anti-infective therapy)
• Recent myocardial infarction (relative contraindication)

Warnings and Precautions

• Immunosuppression with increased infection risk
• Hyperglycemia requiring diabetes management
• Psychiatric disturbances including euphoria, insomnia, mood swings
• Adrenal suppression with HPA axis inhibition

• Use with caution in patients with peptic ulcer disease
• Monitor for ocular effects (cataracts, glaucoma)
• Assess bone mineral density with prolonged therapy
• Taper gradually to avoid adrenal insufficiency
• Avoid abrupt withdrawal after prolonged therapy

Drug Interactions

• Anticoagulants: Altered anticoagulant effect
• Antidiabetic agents: Reduced hypoglycemic efficacy
• CYP3A4 inducers (phenytoin, rifampin): Reduced triamcinolone efficacy
• CYP3A4 inhibitors (ketoconazole): Increased triamcinolone exposure
• Diuretics: Enhanced potassium wasting
• NSAIDs: Increased GI ulcer risk
• Vaccines: Reduced vaccine efficacy; avoid live vaccines

Adverse Effects

• Insomnia
• Increased appetite
• Weight gain
• Fluid retention
• Mood changes
• Hyperglycemia
• Hypertension

• Adrenal suppression
• Cushing's syndrome
• Osteoporosis
• Aseptic necrosis of bone
• Peptic ulcer disease
• Opportunistic infections
• Posterior subcapsular cataracts
• Glaucoma
• Pancreatitis

Monitoring Parameters

• Complete blood count
• Electrolytes, glucose
• Blood pressure
• Bone density (if long-term use anticipated)
• Ophthalmologic examination
• Weight and height (pediatrics)

• Blood glucose levels
• Blood pressure
• Weight changes
• Signs of infection
• Mood and sleep patterns
• Growth velocity (children)
• Bone density (annually if long-term therapy)

Patient Education

• Take with food to minimize GI upset
• Do not stop medication abruptly without medical supervision
• Report any signs of infection (fever, sore throat)
• Monitor for weight gain and swelling
• Regular eye examinations recommended with prolonged use
• Inform all healthcare providers of corticosteroid use
• Carry medical identification indicating steroid use
• Avoid exposure to infections when possible
• Report mood changes or sleep disturbances

• Topical: Use sparingly, avoid occlusive dressings unless directed
• Inhalation: Rinse mouth after use to prevent oral thrush
• Injection: Report any pain, redness, or swelling at injection site

References

1. Lexicomp Online. Triamcinolone monograph. Wolters Kluwer Clinical Drug Information, 2023. 2. Joint Formulary Committee. British National Formulary. London: BMJ Group and Pharmaceutical Press, 2023. 3. Becker DE. Basic and clinical pharmacology of glucocorticosteroids. Anesth Prog. 2013;60(1):25-32. 4. Liu D, 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. FDA Prescribing Information: Kenalog (triamcinolone acetonide). Revised 2022. 6. Barnes PJ. Anti-inflammatory actions of glucocorticoids: molecular mechanisms. Clin Sci (Lond). 1998;94(6):557-72. 7. Coutinho AE, Chapman KE. The anti-inflammatory and immunosuppressive effects of glucocorticoids, recent developments and mechanistic insights. Mol Cell Endocrinol. 2011;335(1):2-13.