Triamcinolone

Mechanism of Action

Triamcinolone falls under the corticosteroid drug class—specifically, it is a glucocorticoid. It exhibits anti-inflammatory and immunosuppressant activity via inhibiting the phospholipase A2 enzyme on the cell membrane phospholipid layer, thereby hindering the breakdown of leukocyte lysosomal membranes and preventing the formation of arachidonic acid.[6] It ultimately decreases the expression of cyclooxygenase (COX) and lipoxygenase (LOX) and thus prevents the biosynthesis of prostaglandins and leukotrienes, respectively. Corticosteroids manifest anti-inflammatory effects via inhibiting macrophage and leukocyte migration to the affected site by reversing vascular dilation and permeability. These actions lead to reduced edema, erythema, and pruritus. An important anti-inflammatory mechanism gets mediated by the inhibition of nuclear factor kappa-B (NF-kappa-B), which leads to decreased protein expression of interleukin-6 (IL-6), interleukin-8 (IL-8), monocyte chemoattractant protein-1 (MCP-1), and COX-2.[7][8]

Triamcinolone metabolism is primarily hepatic, and elimination is via both renal and fecal pathways. The onset of action and duration of triamcinolone varies because it depends on the route of administration in the body. The medication has a rapid absorption rate in the body following oral intake. Triamcinolone has a half-life of between 18 to 36 hours, and peak triamcinolone concentrations occur within 1.5 to 2 hours following oral administration.

Administration

Triamcinolone administration can be oral (e.g., tablets or capsules), topical (e.g., cream and ointment), oral or intranasal topical(e.g., spray), intramuscular, or via intravitreal injection. Triamcinolone, when given orally, should be taken with meals to avoid GI discomfort. When given topically, instructions are to apply a thin layer to the affected area and rub gently. When administered as an inhalation solution, the patient must learn the proper administration technique for the correct dose.[9]

The injectable suspension formulation is available in strengths of 5 mg, 10 mg, 20 mg, and 40 mg/mL. The topical cream/ointment is available in 0.025%, 0.1%, and 0.5% formulations. There is a 0.1% dental paste formulation.

A list of some regimens for conditions organized by dosage form:

Seasonal Allergic Rhinitis

• In adults and children ages 12 and older: 220 mcg daily via intranasal spray (1 to 2 actuations sprays in each nostril; start with 2 actuations - do not exceed 2 actuations in each nostril per day.) Discontinue in 3 weeks if there is no improvement.
• In children:
  • Ages 2 to 5: 110 mcg daily via intranasal spray (1 actuation in each nostril); do not exceed 110 mcg (1 actuation) daily in children under the age of 6. Discontinue in 3 weeks if there is no improvement.
  • Ages 6 to 11: 110 mcg to 220 mcg daily via intranasal spray (1 to 2 actuations sprays in each nostril; start with 1 actuation - do not exceed 2 actuations in each nostril per day.) Discontinue in 3 weeks if there is no improvement.

Various skin conditions (atopic dermatitis, contact dermatitis, dermatitis herpetiformis, psoriasis, eczema, or lichen planus):

• Topical cream or ointment:
  • In adults: apply 0.1% triamcinolone paste twice or three times daily to the affected area after meals.

Dermatomyositis or symptomatic sarcoidosis

• IM form:
  • In adults: the dose ranges between 40 to 80 mg IM daily. Start with 60 mg for one dose; use the lowest effective dose; frequency will vary based on the condition and severity.
  • In pediatrics: dose range 0.11 to 1.6 mg/kg/day divided into 3 or 4 doses.

• Topical cream or ointment:
  • In adults: apply either 0.025% to 0.05% cream/ointment, or 0.1% to 0.5% cream/ointment twice or three times daily to the affected area 

Steroid Responsive Dermatoses (including atopic and contact dermatitis)

• Topical cream or ointment:
  • Apply a thin film of 0.025% cream or ointment to the affected areas 2 to 4 times daily.
  • Injection: INject intralesionally or sub-lesional up to 0.5 mg/square inch of affected skin

Symptomatic relief of rheumatoid arthritis, gouty arthritis, osteoarthritis

• IM form:
  • In adults: the dose ranges between 40 to 80 mg IM; repeat every four weeks.
  • In pediatrics: 40 mg IM, repeat every four weeks.

Hay fever/pollen

• 40 to 100 mg IM as a single injection per season

Intra-articular injection and tendon sheaths (including gout)

• Large joints: inject 5 to 15 mg intraarticular once; may need up to 40 mg.
• Small joints: inject 2.5 to 5 mg intraarticular once; may need up to 10 mg.
• Tendon sheaths: inject 2.5 to 10 mg along the sheath once

Adverse Effects

Common adverse effects associated with the initial use of topical triamcinolone involve itchiness, burning, irritation, or drying of the skin.[10] These symptoms resolve on their own within a few days of use. Other adverse effects may include headaches, dizziness, edema of the ankles or feet, or changes in urination or vision. Chronic use of glucocorticoids such as triamcinolone may cause "Cushing syndrome"; hypertension, weight gain, acne, striae, thinning of the dermal skin layer, osteoporosis, hyperglycemia, amenorrhea, immunosuppression, and steroid psychosis (e.g., depression or mania).[11][12][13]

Patients with congestive heart failure or severe hypertension may experience a higher incidence of edema and weight gain when taking triamcinolone. Glucocorticoid drugs must be slowly tapered off with chronic use to prevent the occurrence of adrenal insufficiency (high risk if the drug is abruptly discontinued, especially in very ill patients).

Contraindications

Triamcinolone injections are strongly contraindicated for epidural administration due to serious medical adverse effects, including paralysis, cortical blindness, and death. Additionally, prolonged use of glucocorticoids may lead to hypothalamic-pituitary-adrenal (HPA) suppression.[14][15] In patients with head trauma, high doses of corticosteroids are not recommended due to the risk of early mortality. Systemic corticosteroids are not indicated for use in fungal or viral infections. Contraindications to triamcinolone include patients with tuberculosis due to the risk of reactivation. 

Patients diagnosed with diabetes mellitus should use caution when systemically dosing triamcinolone (as with all corticosteroids) due to its hyperglycemic adverse effect. A higher incidence of skin atrophy is noted with glucocorticoid use in the elderly population due to aging. Patients diagnosed with psychosis should also use extreme caution as triamcinolone may cause exacerbation of related symptoms.

Corticosteroids are known to exacerbate glaucoma; thus, primary care physician supervision is necessary.[16] Pregnant patients should not use triamcinolone for prolonged use due to potency. Corticosteroid use is contraindicated in children under the age of two.

Monitoring

Patients taking triamcinolone should undergo monitoring to relieve symptoms and any adverse effects. The liver (LFTs) and kidney (BUN and creatinine concentrations) function also require monitoring in individuals with hepatic or renal impairment, and dose adjustment is made accordingly.[17][18] It is essential to monitor the cardiac function in patients with a past medical history of congestive heart failure or arrhythmias. 

Triamcinolone should be stored in a cool, dry area at room temperature (between 68 to 77 degrees F).

Toxicity

Glucocorticoids such as triamcinolone can cause variable neuropsychiatric symptoms to develop. Examples of these symptoms include mania, depression, delirium, and psychosis.[19] These symptoms and other cognitive issues resulting from taking triamcinolone can be reversible after discontinuing the medication. Researchers have noted an increased risk of suicide in patients on chronic glucocorticoid therapy, so its use warrants caution. Cardiovascular effects can also be seen in patients using triamcinolone. Premature atherosclerosis, hypertension, fluid retention, and arrhythmias can occur in these patients, especially when prescribing a higher drug dosage. Many of these cardiovascular issues are likely to disappear upon discontinuation of triamcinolone.

Enhancing Healthcare Team Outcomes

Managing the administration of triamcinolone requires an interprofessional team consisting of a primary care clinician (MD, DO, NP, PA), pharmacist, nurse, and other specialty clinicians such as an allergist or dermatologist. An immunologist may also be called upon to evaluate immune system processes affected by the administration of triamcinolone. The interprofessional team must instruct patients on the proper technique for applying triamcinolone. The healthcare team should be vigilant regarding adverse effects as well as therapeutic outcomes of triamcinolone. Nursing can verify patient adherence, answer questions, provide counsel, and monitor for adverse events and treatment effectiveness, informing the clinician of any concerns that may arise. Pharmacists should be involved with recommendations regarding dosing and storage. Additionally, a clinical pharmacologist consult is necessary if the patient is experiencing toxicity symptoms. Regular follow-up with the patient is prudent to assess for abnormalities and drug efficacy.

To summarize, triamcinolone therapy requires an interprofessional team approach, including clinicians, specialists, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient outcomes. [Level 5]