Version July 2025
Dosage guidance:
Dosing: Adjust dose depending upon condition being treated and response of patient. Use the lowest possible dose to control the condition; when dose reduction is possible, reduce gradually.
Dermatoses (steroid-responsive): Acetonide: Note: Available preparations may be further diluted using appropriate diluents (eg, NS or lidocaine) to concentrations (eg, 1 to 10 mg/mL) appropriate for the lesion (Ref).
Intralesional: Initial dose varies depending on the specific disease and lesion being treated; for larger treatment areas some experts recommend not to exceed 40 mg per treatment session (Ref); may be repeated every 3 to 4 weeks or less frequently (eg, every 6 weeks); multiple sites may be injected if they are ≥1 cm apart (Ref).
Gout, treatment, acute flares:
Note: Avoid use in patients with known or suspected septic arthritis (Ref).
Intra-articular: Acetonide: Note: Consider in patients with gout flare limited to 1 or 2 affected joints; clinicians must have sufficient expertise to perform arthrocentesis and injection (Ref). May mix with an equal volume of local anesthetic (Ref). Dose is individualized based on joint size, disease severity, and clinician judgment (Ref). Typical doses are:
Large joint (eg, knee): 40 mg as a single dose (Ref).
Medium joint (eg, wrist, ankle, elbow): 30 mg as a single dose (Ref).
Small joint (eg, toe, finger): 10 mg as a single dose (Ref).
IM (alternative route): Acetonide (use Kenalog-40 or Kenalog-80): Note: Reserve for patients who are not candidates for oral therapies or intra-articular glucocorticoid administration.
Initial: 40 to 60 mg as a single dose; may repeat at ≥48-hour intervals if benefit fades or there is no flare resolution (Ref).
Inflammatory/Allergic conditions/other steroid-responsive systemic conditions: Acetonide (use Kenalog-40 or Kenalog-80): IM: Initial: 60 mg; adjust dose to a range of 40 to 80 mg. For patients with hay fever or pollen asthma who are not responding to pollen administration and other conventional therapy, a single injection of 40 to 100 mg per season may be given.
Multiple sclerosis (acute exacerbation):
Note: Treatment guidelines recommend the use of high dose IV or oral methylprednisolone for acute exacerbations of multiple sclerosis (Ref).
Acetonide (use Kenalog-40 or Kenalog-80): IM: 160 mg daily for 1 week, followed by 64 mg every other day for 1 month.
Rheumatic conditions (excluding acute gout flares):
Intra-articular (or similar injection as designated): Note: Dose ranges per manufacturer's labeling. Specific dose is determined based upon joint size, severity of inflammation, amount of articular fluid present, and clinician judgment.
Acetonide: Intra-articular, intrabursal, tendon sheaths: Initial: Smaller joints: 2.5 to 5 mg, larger joints: 5 to 15 mg; may require up to 10 mg for small joints and up to 40 mg for large joints; maximum dose/treatment (several joints at one time): 80 mg.
Zilretta only: Intra-articular: Single dose: 32 mg. Note: For osteoarthritis (OA) pain of the knee only (use for OA pain of shoulder and hip have not been evaluated); use is not suitable for small joints (eg, hand). Safety and efficacy of repeat administration have not been adequately demonstrated.
Hexacetonide: Note: Due to an ongoing shortage of triamcinolone hexacetonide in the United States, the FDA has temporarily authorized the importation of Hexatrione 2% injectable suspension (40 mg/2 mL).
Intra -articular: Average dose: 2 to 20 mg; smaller joints (interphalangeal, metacarpophalangeal): 2 to 6 mg; large joints (knee, hip, shoulder): 10 to 20 mg. Frequency of injection into a single joint is every 3 to 4 weeks as necessary; to avoid possible joint destruction use as infrequently as possible.
IM: Acetonide (use Kenalog-40 or Kenalog-80): Initial: 60 mg; range: 2.5 to 100 mg/day.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling; use with caution.
There are no dosage adjustments provided in the manufacturer's labeling; use with caution.
Infection: Consider dosage reduction or discontinuing triamcinolone as needed.
Refer to adult dosing.
(For additional information see "Triamcinolone (systemic): Pediatric drug information")
Dosage guidance:
Dosing: Adjust dose depending upon condition being treated and response of patient. The lowest possible dose should be used to control the condition; when dose reduction is possible, the dose should be reduced gradually.
General dosing, treatment of inflammatory and allergic conditions:
Children and Adolescents: Triamcinolone acetonide (Kenalog-40): IM: Initial: 0.11 to 1.6 mg/kg/day (or 3.2 to 48 mg/m2/day) in 3 to 4 divided doses.
Juvenile idiopathic arthritis (JIA), other rheumatic conditions:
Triamcinolone acetonide (Kenalog-10, -40, or -80): Children and Adolescents: Intra-articular: Initial: Smaller joints: 2.5 to 5 mg, larger joints: 5 to 15 mg; maximum dose/treatment (several joints at one time): 20 to 80 mg.
Canadian labeling: Triamcinolone hexacetonide (Canadian product; not available in the US):
Children 3 to 12 years: Intra-articular:
Large joints (knees, hips, shoulders): 1 mg/kg/dose.
Small joints (ankles, wrists, elbows): 0.5 mg/kg/dose.
Hands and feet:
Metacarpophalangeal/metatarsophalangeal joints: 1 to 2 mg/dose.
Proximal interphalangeal joints: 0.6 to 1 mg/dose.
Adolescents: Intra-articular: Average dose: 2 to 20 mg/dose every 3 to 4 weeks as necessary; to avoid possible joint destruction use as infrequently as possible. Dose dependent upon degree of inflammation and joint involved:
Large joints (knee, hip, shoulder): 10 to 20 mg/dose.
Smaller joints (interphalangeal, metacarpophalangeal): 2 to 6 mg/dose.
Infantile hemangioma, severe: Limited data available: Infants and Children ≤49 months: Triamcinolone acetonide (Kenalog-10 or -40): Intralesional: Dosage dependent upon size of lesion: Commonly reported: 1 to 2 mg/kg/dose administered in divided doses along the lesion perimeter ~monthly (4 to 5 weeks most frequently reported interval); a maximum dose up to 30 mg/dose has been used; others have reported: 1 to 30 mg of the 10 mg/mL acetonide injection divided into multiple injections along the lesion; has also been used in combination with betamethasone intralesional injections (Ref). From the largest reported experience (n=1,514; age range: 1 to 49 months), triamcinolone (1 to 2 mg/kg once every month) alone or in combination with oral corticosteroid (if no response after 6 injections of monotherapy) showed lesion size decrease of 50% or more in 90.3% of infants (age <1 year) and 80% in those >1 year (Ref). Another trial (n=155; age range at first injection: 2 to 12 months) which used 1 to 30 mg of a 10 mg/mL concentration administered approximately once monthly (mean interval: 5 weeks) for 3 to 6 months showed lesion size decreased by at least 50% in 85% of the patients (Ref).
Dermatoses (steroid-responsive, including contact/atopic dermatitis):
Triamcinolone acetonide (Kenalog-10): Intradermal: Adolescents: Up to 1 mg per injection site and may be repeated 1 or more times weekly; multiple sites may be injected if they are 1 cm or more apart, not to exceed 30 mg.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling.
There are no dosage adjustments provided in the manufacturer's labeling.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Most reactions listed are based on reports for other agents in this same pharmacologic class and may not be specifically reported for systemic triamcinolone.
1% to 10%:
Hematologic & oncologic: Bruise (extended release: 2%)
Neuromuscular & skeletal: Joint swelling (extended release: 3%)
Respiratory: Cough (extended release: 2%), sinusitis (extended release: 2%)
Frequency not defined:
Cardiovascular: Bradycardia, cardiac arrhythmia, cardiac failure, cardiomegaly, cerebrovascular accident, circulatory shock, edema, embolism (fat), hypertension, hypertrophic cardiomyopathy (premature infants), myocardial rupture (following recent myocardial infarction), syncope, tachycardia, thromboembolism, thrombophlebitis, vasculitis
Dermatologic: Acne vulgaris, allergic dermatitis, atrophic striae, diaphoresis, ecchymoses, epidermal thinning, erythema of skin, exfoliation of skin, hyperpigmentation, hypertrichosis, hypopigmentation, inadvertent suppression of skin test reaction, skin atrophy, skin rash, subcutaneous atrophy, thinning hair, urticaria, xeroderma
Endocrine & metabolic: Calcinosis, decreased glucose tolerance, decreased serum potassium, diabetes mellitus, drug-induced Cushing's syndrome, fluid retention, glycosuria, growth retardation, hirsutism, impaired glucose tolerance/prediabetes, insulin resistance, menstrual disease, moon face, negative nitrogen balance, pituitary insufficiency, redistribution of body fat, secondary adrenocortical insufficiency, sodium retention, weight gain
Gastrointestinal: Abdominal distention, change in bowel habits, gastrointestinal hemorrhage, gastrointestinal perforation, hiccups, increased appetite, nausea, pancreatitis, peptic ulcer, ulcerative esophagitis
Genitourinary: Bladder dysfunction, postmenopausal bleeding, spermatozoa disorder
Hematologic & oncologic: Nonthrombocytopenic purpura, petechia, purpuric rash
Hepatic: Hepatomegaly, increased liver enzymes
Hypersensitivity: Anaphylaxis, angioedema
Infection: Increased susceptibility to infection, infection, sterile abscess
Local: Post-injection flare
Nervous system: Abnormal sensory symptoms, arachnoiditis, depression, emotional lability, euphoria, headache, idiopathic intracranial hypertension (upon discontinuation), increased intracranial pressure, insomnia, malaise, meningitis, mood changes, myasthenia, neuritis, neuropathy, paraplegia, paresthesia, personality changes, psychiatric disturbance, quadriplegia, seizure, spinal cord infarction, vertigo
Neuromuscular & skeletal: Amyotrophy, aseptic necrosis of femoral head, aseptic necrosis of humeral head, bone fracture, Charcot arthropathy, lupus erythematous-like rash, osteoporosis, rupture of tendon, steroid myopathy, vertebral compression fracture
Ophthalmic: Blindness (periocular; rare), cataract (including subcapsular posterior cataract), cortical blindness, exophthalmos, glaucoma, increased intraocular pressure, papilledema
Renal: Increased urine calcium excretion
Respiratory: Pulmonary edema
Miscellaneous: Wound healing impairment
Postmarketing:
Dermatologic: Pruritus
Endocrine & metabolic: Increased serum glucose (in diabetic patients)
Hypersensitivity: Hypersensitivity reactions
Local: Discomfort at injection site, pain at injection site
Nervous system: Pain
Neuromuscular & skeletal: Arthralgia, joint effusion, lower extremity pain, muscle spasm, septic arthritis
Triamcinolone acetonide: Hypersensitivity to triamcinolone or any component of the formulation; immune thrombocytopenia (formerly known as idiopathic thrombocytopenic purpura) (IM administration only)
Canadian labeling: Additional contraindications (not in US labeling): Systemic infections; injection into infected areas
Triamcinolone hexacetonide [Canadian product]: Hypersensitivity to triamcinolone or any component of the formulation; acute psychoses; tuberculosis (TB) disease (active TB); herpes simplex keratitis; systemic mycoses; parasitosis (strongyloides infections); children <3 years of age (due to benzyl alcohol); epidural or intrathecal administration
Concerns related to adverse effects:
• Adrenal suppression: May cause hypercortisolism or suppression of hypothalamic-pituitary-adrenal (HPA) axis, particularly in younger children or in patients receiving high doses for prolonged periods. HPA axis suppression may lead to adrenal crisis. Withdrawal and discontinuation of a corticosteroid should be done slowly and carefully. Particular care is required when patients are transferred from systemic corticosteroids to inhaled products due to possible adrenal insufficiency or withdrawal from steroids, including an increase in allergic symptoms. Adult patients receiving >20 mg per day of prednisone (or equivalent) may be most susceptible. Fatalities have occurred due to adrenal insufficiency in asthmatic patients during and after transfer from systemic corticosteroids to aerosol steroids; aerosol steroids do not provide the systemic steroid needed to treat patients having trauma, surgery, or infections.
• Anaphylactoid reactions: Rare cases of anaphylactoid reactions have been observed in patients receiving corticosteroids. Cases of serious anaphylaxis, including death, have been reported with triamcinolone acetonide.
• Dermal changes: Atrophy at the injection site has been reported. Avoid IM deltoid injection; subcutaneous atrophy may occur.
• Immunosuppression: Corticosteroids suppress the immune system and increase risk of infection with any pathogen, including bacterial, fungal, helminthic, protozoan, or viral; severe and sometimes fatal corticosteroid-associated infections have occurred. Corticosteroids may reduce resistance to new infections, exacerbate existing infections, increase the risk of disseminated infections, increase the risk of reactivation or exacerbation of latent infections, mask some signs of infection. Avoid exposure to varicella or measles; if exposure occurs, prophylaxis with an appropriate immunoglobulin may be indicated; antiviral treatment may be considered if varicella infection occurs. Tuberculosis (TB) reactivation may occur when treating patients with latent TB or tuberculin reactivity; administer chemoprophylaxis in patients with latent TB or tuberculin reactivity during prolonged use of triamcinolone. Avoid use in patients with active ocular herpes simplex. Hepatitis B reactivation can occur (infrequently) in patients who are hepatitis B carriers. For patients who show evidence of hepatitis B infection, consult an infectious disease specialist regarding monitoring and treatment options before initiating triamcinolone. May exacerbate systemic fungal infections. Amebiasis reactivation may occur. Use with extreme caution in patients with Strongyloides infections; hyperinfection, dissemination, and fatalities have occurred. Avoid use in patients with cerebral malaria.
• Kaposi sarcoma: Prolonged treatment with corticosteroids has been associated with the development of Kaposi sarcoma; clinical improvement may occur with triamcinolone discontinuation.
• Myopathy: Acute myopathy has been reported with high-dose corticosteroids, usually in patients with neuromuscular transmission disorders or when given concomitantly with neuromuscular blocking agents; may involve ocular and/or respiratory muscles; monitor creatine kinase; recovery may be delayed.
• Psychiatric disturbances: Corticosteroid use may cause psychiatric disturbances, including euphoria, insomnia, mood swings, and personality changes to severe depression and frank psychotic manifestations. Preexisting psychiatric conditions may be exacerbated by corticosteroid use.
• Septic arthritis: May occur as a complication to intra-articular or soft tissue administration; institute appropriate antimicrobial therapy as required.
Disease-related concerns:
• Cardiovascular disease: Use with caution in patients with HF and/or hypertension; use has been associated with fluid retention, electrolyte disturbances, and hypertension. Use with caution following acute MI; corticosteroids have been associated with myocardial rupture.
• Diabetes: Use corticosteroids with caution in patients with diabetes mellitus; may alter glucose production/regulation leading to hyperglycemia.
• Gastrointestinal disease: Use with caution or avoid use in patients with GI diseases (diverticulosis, diverticulitis, fresh intestinal anastomoses, active or latent peptic ulcer, ulcerative colitis, abscess or other pyogenic infection) due to perforation risk.
• Head injury: Increased mortality was observed in patients receiving high-dose IV methylprednisolone; high-dose corticosteroids should not be used for the management of head injury.
• Hepatic impairment: Use with caution in patients with hepatic impairment, including cirrhosis; long-term use has been associated with fluid retention.
• Myasthenia gravis: Use may cause transient worsening of myasthenia gravis (MG) (eg, within first 2 weeks of treatment); monitor for worsening MG (AAN [Narayanaswami 2021]).
• Ocular disease: Use with caution in patients with cataracts and/or glaucoma; increased intraocular pressure, open-angle glaucoma, and cataracts have occurred with prolonged use. Use with caution in patients with a history of ocular herpes simplex; corneal perforation has occurred; do not use in active ocular herpes simplex. Not recommended for the treatment of optic neuritis; may increase frequency of new episodes. Consider routine eye exams in chronic users.
• Osteoporosis: Use with caution in patients with osteoporosis; high doses and/or long-term use of corticosteroids have been associated with increased bone loss and osteoporotic fractures.
• Renal impairment: Use with caution in patients with renal impairment; fluid retention may occur.
• Seizure disorders: Use corticosteroids with caution in patients with a history of seizure disorder; seizures have been reported with adrenal crisis.
• Systemic sclerosis: Use with caution in patients with systemic sclerosis; an increase in scleroderma renal crisis incidence has been observed with corticosteroid use. Monitor BP and renal function in patients with systemic sclerosis treated with corticosteroids (EULAR [Kowal-Bielecka 2017]).
• Thyroid disease: Changes in thyroid status may necessitate dosage adjustments; metabolic clearance of corticosteroids increases in hyperthyroid patients and decreases in hypothyroid ones.
Special populations:
• Older adult: Use with caution in the elderly with the smallest possible effective dose for the shortest duration.
• Pediatric: May affect growth velocity; growth should be routinely monitored in pediatric patients.
Dosage form specific issues:
• Benzyl alcohol and derivatives: Some dosage forms may contain benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997], CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol with caution in neonates. See manufacturer's labeling.
• Polysorbate 80: Some dosage forms may contain polysorbate 80 (also known as Tweens). Hypersensitivity reactions, usually a delayed reaction, have been reported following exposure to pharmaceutical products containing polysorbate 80 in certain individuals (Isaksson 2002, Lucente 2000, Shelley 1995). Thrombocytopenia, ascites, pulmonary deterioration, and renal and hepatic failure have been reported in premature neonates after receiving parenteral products containing polysorbate 80 (Alade 1986; CDC 1984). See manufacturer's labeling.
Other warnings/precautions:
• Appropriate administration: Administer products only via recommended route (depending on product used). Do not administer any triamcinolone product via the intrathecal route; serious adverse events, including fatalities, have been reported following intrathecal administration of corticosteroids.
• Discontinuation of therapy: Withdraw therapy with gradual tapering of dose.
• Epidural injection: Corticosteroids are not approved for epidural injection. Serious neurologic events (eg, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, stroke), some resulting in death, have been reported with epidural injection of corticosteroids, with and without use of fluoroscopy.
• Immunizations: Avoid administration of live or live attenuated vaccines in patients receiving immunosuppressive doses of corticosteroids. Nonlive or inactivated vaccines may be administered, although the response cannot be predicted.
• Intra-articular injection: May result in damage to joint tissues. Avoid injection into an infected site; injection into a previously infected joint is not usually recommended. Injection into unstable joints is generally not recommended. Examine any joint fluid present to exclude a septic process.
• Stress: Patients may require higher doses when subject to stress (ie, trauma, surgery, severe infection).
Adrenal suppression with failure to thrive has been reported in infants and young children receiving intralesional corticosteroid injections for the treatment of infantile hemangioma; failure to gain weight may persist until HPA axis recovers; time to recovery of adrenal function may be prolonged (mean: 19.5 weeks; range 4 to 65 weeks) (DeBoer 2008; Morkane 2011). May cause osteoporosis (at any age) or inhibition of bone growth in pediatric patients. Use with caution in patients with osteoporosis. In a population-based study of children, risk of fracture was shown to be increased with >4 courses of corticosteroids; underlying clinical condition may also impact bone health and osteoporotic effect of corticosteroids (Leonard 2007). Tissue atrophy at the site of IM injection has been reported; avoid intramuscular injections into the deltoid area. Cutaneous atrophy was reported in 2.5% of pediatric patients when given intra-articularly (Bloom 2011). Prevention of periarticular subcutaneous atrophy via injecting small amounts of saline into the joint and applying pressure following the injection has been recommended (Hashkes 2005).
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Suspension, Injection, as acetonide:
Kenalog-10: 10 mg/mL (5 mL) [contains benzyl alcohol, polysorbate 80]
Kenalog-40: 40 mg/mL (1 mL, 5 mL, 10 mL) [contains benzyl alcohol, polysorbate 80]
Kenalog-80: 80 mg/mL (1 mL, 5 mL) [contains benzyl alcohol, polysorbate 80]
Generic: 40 mg/mL (1 mL, 5 mL, 10 mL)
Suspension, Intra-articular, as hexacetonide:
Hexatrione: 20 mg/mL (2 mL) [contains benzyl alcohol, polysorbate 80]
Suspension Reconstituted ER, Intra-articular, as acetonide:
Zilretta: 32 mg (1 ea) [contains polysorbate 80]
May be product dependent
Kit (Pro-C-Dure 5 Injection)
2 X 40 mg/mL (per each): $600.49
Kit (Pro-C-Dure 6 Injection)
3 X 40 mg/mL (per each): $736.45
Suspension (Hexatrione Intra-articular)
20 mg/mL (per mL): $39.00
Suspension (Kenalog-10 Injection)
10 mg/mL (per mL): $2.90
Suspension (Kenalog-40 Injection)
40 mg/mL (per mL): $11.40
Suspension (Kenalog-80 Injection)
80 mg/mL (per mL): $22.46
Suspension (Triamcinolone Acetonide Injection)
40 mg/mL (per mL): $6.24 - $10.67
Suspension Reconstituted ER (Zilretta Intra-articular)
32 mg (per each): $808.81
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Suspension, Injection, as acetonide:
Kenalog-10: 10 mg/mL (5 mL)
Kenalog-40: 40 mg/mL (1 mL, 5 mL)
Generic: 40 mg/mL (1 mL, 5 mL)
Suspension, Injection, as hexacetonide:
Trispan: 20 mg/mL ([DSC]) [contains benzyl alcohol, polysorbate 80]
Shake well before use to ensure suspension is uniform. Do not use if agglomerated (clumpy or granular appearance); administer immediately after withdrawal so settling does not occur in the syringe. Do not administer any product IV or via the epidural or intrathecal route.
Acetonide:
Kenalog-10 injection: For intra-articular or intralesional administration only. When administered intralesionally, inject directly into the lesion (ie, into the mid-dermis). One mL syringes with a 30-gauge needle are preferable for intralesional injections (Ref).
Kenalog-40 and Kenalog-80 injection: For intra-articular, intralesional (off-label route), soft tissue or IM administration. When administered intralesionally, inject directly into the lesion (ie, into the mid-dermis). One mL syringes with a 30-gauge needle are preferable for intralesional injections (Ref). When administered IM, inject deep into the gluteal muscle using a minimum needle length of 11/2 inches. Obese patients may require a longer needle. Alternate sites for subsequent injections. Avoid IM injections into deltoid area.
Zilretta injection: For intra-articular administration only. Prepare suspension only using the diluent supplied in the kit (refer to manufacturer labeling for preparation instructions and administration techniques). Promptly inject after preparation. If needed, may store suspension in the vial ≤4 hours at ambient conditions; gently swirl vial to resuspend any settled microspheres prior to preparing syringe for injection. Aspiration of synovial fluid may be performed based on clinical judgment prior to administration.
Hexacetonide [Canadian product]: For intra-articular and soft tissue administration only; use a 25- or 26-gauge needle.
Note: Due to an ongoing shortage of triamcinolone hexacetonide in the United States, the FDA has temporarily authorized the importation of Hexatrione 2% injectable suspension (40 mg/2 mL). According to the manufacturer, Hexatrione is for intra-articular administration only and should NOT be injected into soft tissue (synovial tendon sheaths, entheses). Additional administration-related information is available at https://www.fda.gov/media/154709/download.
Parenteral: Shake well before use to ensure suspension is uniform. Inspect visually to ensure no clumping; administer immediately after withdrawal so settling does not occur in the syringe. Do not administer any product IV or via the epidural or intrathecal route.
Acetonide:
Kenalog-10 injection: For intra-articular or intralesional administration only. When administered intralesionally, inject directly into the lesion (ie, intradermally or subcutaneously). Tuberculin syringes with a 23- to 25-gauge needle are preferable for intralesional injections. For infantile hemangioma, 27- and 30-gauge needles have been used (Ref).
Kenalog-40, -80 injection: For intra-articular, soft tissue or IM administration. When administered IM, inject deep into the gluteal muscle using a minimum needle length of 11/2 inches for adults. Obese patients may require a longer needle. Alternate sites for subsequent injections. Avoid IM injections into deltoid area.
Hexacetonide [Canadian product]: For intra-articular and soft tissue administration only; use a 25- or 26-gauge needle.
Certain lesions (intralesional administration with triamcinolone acetonide [Kenalog-10]): Note: Other concentrations (ie, Kenalog-40 and Kenalog-80) may also be used off label; may require further dilution using appropriate diluents to concentrations appropriate for the lesion (Mathes 2021):
Alopecia areata; discoid lupus erythematosus; keloids; localized hypertrophic, infiltrated, inflammatory lesions of granuloma annulare, lichen planus, lichen simplex chronicus (neurodermatitis), and psoriatic plaques; necrobiosis lipoidica diabeticorum; cystic tumors of an aponeurosis or tendon (ganglia).
Inflammatory joint diseases (subacute and chronic) (intra-articular or soft tissue administration with triamcinolone acetonide [Kenalog-10, Kenalog-40, Kenalog-80] or triamcinolone hexacetonide [Canadian product]):
Acute gouty arthritis, synovitis, tendinopathy, bursitis, epicondylitis, rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), osteoarthritis, or post-traumatic arthritis.
Other conditions (IM administration with triamcinolone acetonide [Kenalog-40 or Kenalog-80]):
Allergic states: Control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment in asthma, drug hypersensitivity reactions, perennial or seasonal allergic rhinitis, serum sickness, or transfusion reactions.
Dermatologic diseases: Atopic dermatitis, bullous dermatitis herpetiformis, contact dermatitis, exfoliative erythroderma, mycosis fungoides, pemphigus, or severe erythema multiforme (Stevens-Johnson syndrome).
Endocrine disorders: Primary or secondary adrenocortical insufficiency (hydrocortisone or cortisone is the drug of choice), congenital adrenal hyperplasia, hypercalcemia associated with cancer, or nonsuppurative thyroiditis.
GI diseases: To tide the patient over a critical period of disease in Crohn disease or ulcerative colitis.
Hematologic disorders: Acquired (autoimmune) hemolytic anemia, Diamond-Blackfan anemia, pure red cell aplasia, select cases of secondary thrombocytopenia.
Neoplastic diseases: Palliative management of leukemias and lymphomas.
Nervous system: Acute exacerbations of multiple sclerosis; cerebral edema associated with primary or metastatic brain tumor or craniotomy. Note: Treatment guidelines recommend the use of high dose IV or oral methylprednisolone for acute exacerbations of multiple sclerosis (AAN [Scott 2011]; NICE 2014).
Ophthalmic diseases: Sympathetic ophthalmia, temporal arteritis, uveitis, and ocular inflammatory conditions unresponsive to topical corticosteroids.
Renal diseases: To induce diuresis or remission of proteinuria in idiopathic nephrotic syndrome or that is caused by lupus erythematosus.
Respiratory diseases: Berylliosis, fulminating or disseminated pulmonary tuberculosis when used concurrently with appropriate antituberculous chemotherapy, idiopathic eosinophilic pneumonias, symptomatic sarcoidosis.
Rheumatic disorders: As adjunctive therapy for short-term administration in acute gout flares; acute rheumatic carditis; ankylosing spondylitis; psoriatic arthritis; RA, including juvenile RA; treatment of dermatomyositis, polymyositis, and systemic lupus erythematosus.
Miscellaneous: Trichinosis with neurologic or myocardial involvement; tuberculous meningitis with subarachnoid block or impending block when used with appropriate antituberculous chemotherapy.
Kenalog may be confused with Ketalar
TAC or tac is an error-prone abbreviation (mistaken as tacrolimus; tetracaine, Adrenalin, and cocaine; Taxotere, Adriamycin, and cycloPHOSphamide)
Substrate of CYP3A4 (Minor); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential;
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Abrocitinib: Corticosteroids (Systemic) may increase immunosuppressive effects of Abrocitinib. Management: The use of abrocitinib in combination with other immunosuppressants is not recommended. Doses equivalent to more than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks are considered immunosuppressive. Risk D: Consider Therapy Modification
Acetylcholinesterase Inhibitors: Corticosteroids (Systemic) may increase adverse/toxic effects of Acetylcholinesterase Inhibitors. Increased muscular weakness may occur. Risk C: Monitor
Aldesleukin: Corticosteroids (Systemic) may decrease therapeutic effects of Aldesleukin. Risk X: Avoid
Amphotericin B: Corticosteroids (Systemic) may increase hypokalemic effects of Amphotericin B. Risk C: Monitor
Androgens: Corticosteroids (Systemic) may increase fluid-retaining effects of Androgens. Risk C: Monitor
Antidiabetic Agents: Hyperglycemia-Associated Agents may decrease therapeutic effects of Antidiabetic Agents. Risk C: Monitor
Antithymocyte Globulin (Equine): Corticosteroids (Systemic) may increase adverse/toxic effects of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of systemic corticosteroid is reduced. Corticosteroids (Systemic) may increase immunosuppressive effects of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor
Baricitinib: Corticosteroids (Systemic) may increase immunosuppressive effects of Baricitinib. Management: The use of baricitinib in combination with potent immunosuppressants is not recommended. Doses equivalent to more than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks are considered immunosuppressive. Risk D: Consider Therapy Modification
BCG Products: Corticosteroids (Systemic) may decrease therapeutic effects of BCG Products. Corticosteroids (Systemic) may increase adverse/toxic effects of BCG Products. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Brincidofovir: Corticosteroids (Systemic) may decrease therapeutic effects of Brincidofovir. Risk C: Monitor
Brivudine: May increase adverse/toxic effects of Corticosteroids (Systemic). Risk X: Avoid
Calcitriol (Systemic): Corticosteroids (Systemic) may decrease therapeutic effects of Calcitriol (Systemic). Risk C: Monitor
CAR-T Cell Immunotherapy: Corticosteroids (Systemic) may decrease therapeutic effects of CAR-T Cell Immunotherapy. Corticosteroids (Systemic) may increase adverse/toxic effects of CAR-T Cell Immunotherapy. Specifically, the severity and duration of neurologic toxicities may be increased. Management: Avoid use of corticosteroids as premedication before treatment with CAR-T cell immunotherapy agents. Corticosteroids are indicated and may be required for treatment of toxicities such as cytokine release syndrome or neurologic toxicity. Risk D: Consider Therapy Modification
Cardiac Glycosides: Corticosteroids (Systemic) may increase adverse/toxic effects of Cardiac Glycosides. Risk C: Monitor
Chikungunya Vaccine (Live): Corticosteroids (Systemic) may increase adverse/toxic effects of Chikungunya Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may decrease therapeutic effects of Chikungunya Vaccine (Live). Risk X: Avoid
Cladribine: Corticosteroids (Systemic) may increase immunosuppressive effects of Cladribine. Risk X: Avoid
Coccidioides immitis Skin Test: Coadministration of Corticosteroids (Systemic) and Coccidioides immitis Skin Test may alter diagnostic results. Management: Consider discontinuing systemic corticosteroids (dosed at 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks) several weeks prior to coccidioides immitis skin antigen testing. Risk D: Consider Therapy Modification
Corticorelin: Corticosteroids (Systemic) may decrease therapeutic effects of Corticorelin. Specifically, the plasma ACTH response to corticorelin may be blunted by recent or current corticosteroid therapy. Risk C: Monitor
Cosyntropin: Coadministration of Corticosteroids (Systemic) and Cosyntropin may alter diagnostic results. Risk C: Monitor
COVID-19 Vaccine (Inactivated Virus): Corticosteroids (Systemic) may decrease therapeutic effects of COVID-19 Vaccine (Inactivated Virus). Risk C: Monitor
COVID-19 Vaccine (mRNA): Corticosteroids (Systemic) may decrease therapeutic effects of COVID-19 Vaccine (mRNA). Management: Give a 3-dose primary series for all patients aged 6 months and older taking immunosuppressive medications or therapies. Booster doses are recommended for certain age groups. See CDC guidance for details. Risk D: Consider Therapy Modification
COVID-19 Vaccine (Subunit): Corticosteroids (Systemic) may decrease therapeutic effects of COVID-19 Vaccine (Subunit). Risk C: Monitor
CYP3A4 Inducers (Strong): May decrease serum concentration of Triamcinolone (Systemic). Risk C: Monitor
CYP3A4 Inhibitors (Moderate): May increase serum concentration of Triamcinolone (Systemic). Risk C: Monitor
CYP3A4 Inhibitors (Strong): May increase serum concentration of Triamcinolone (Systemic). Management: Consider alternatives to this combination when possible. If combined, monitor for increased corticosteroid adverse effects during coadministration of triamcinolone and strong CYP3A4 inhibitors. Risk D: Consider Therapy Modification
Deferasirox: Corticosteroids (Systemic) may increase adverse/toxic effects of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased. Risk C: Monitor
Dengue Tetravalent Vaccine (Live): Corticosteroids (Systemic) may decrease therapeutic effects of Dengue Tetravalent Vaccine (Live). Corticosteroids (Systemic) may increase adverse/toxic effects of Dengue Tetravalent Vaccine (Live). Specifically, the risk of vaccine associated infection may be increased. Risk X: Avoid
Denosumab: May increase immunosuppressive effects of Corticosteroids (Systemic). Management: Consider the risk of serious infections versus the potential benefits of coadministration of denosumab and systemic corticosteroids. If combined, monitor patients for signs/symptoms of serious infections. Risk D: Consider Therapy Modification
Desirudin: Corticosteroids (Systemic) may increase anticoagulant effects of Desirudin. More specifically, corticosteroids may increase hemorrhagic risk during desirudin treatment. Management: Discontinue treatment with systemic corticosteroids prior to desirudin initiation. If concomitant use cannot be avoided, monitor patients receiving these combinations closely for clinical and laboratory evidence of excessive anticoagulation. Risk D: Consider Therapy Modification
Desmopressin: Corticosteroids (Systemic) may increase hyponatremic effects of Desmopressin. Risk X: Avoid
Deucravacitinib: May increase immunosuppressive effects of Corticosteroids (Systemic). Management: The use of deucravacitinib in combination with potent immunosuppressants is not recommended. Doses equivalent to more than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks are considered immunosuppressive. Risk D: Consider Therapy Modification
Dinutuximab Beta: Corticosteroids (Systemic) may increase immunosuppressive effects of Dinutuximab Beta. Management: Corticosteroids are not recommended for 2 weeks prior to dinutuximab beta, during therapy and for 1 week after treatment. Doses equivalent to over 2 mg/kg or 20 mg/day of prednisone (persons over 10 kg) for 2 or more weeks are considered immunosuppressive Risk D: Consider Therapy Modification
Estrogen Derivatives: May increase serum concentration of Corticosteroids (Systemic). Risk C: Monitor
Etrasimod: Corticosteroids (Systemic) may increase immunosuppressive effects of Etrasimod. Risk C: Monitor
Filgotinib: Corticosteroids (Systemic) may increase immunosuppressive effects of Filgotinib. Management: Coadministration of filgotinib with systemic corticosteroids at doses equivalent to greater than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks is not recommended. Risk D: Consider Therapy Modification
Gallium Ga 68 Dotatate: Coadministration of Corticosteroids (Systemic) and Gallium Ga 68 Dotatate may alter diagnostic results. Risk C: Monitor
Growth Hormone Analogs: Corticosteroids (Systemic) may decrease therapeutic effects of Growth Hormone Analogs. Growth Hormone Analogs may decrease active metabolite exposure of Corticosteroids (Systemic). Risk C: Monitor
Hyaluronidase: Corticosteroids (Systemic) may decrease therapeutic effects of Hyaluronidase. Management: Patients receiving corticosteroids (particularly at larger doses) may not experience the desired clinical response to standard doses of hyaluronidase. Larger doses of hyaluronidase may be required. Risk D: Consider Therapy Modification
Immune Checkpoint Inhibitors (Anti-PD-1, -PD-L1, and -CTLA4 Therapies): Corticosteroids (Systemic) may decrease therapeutic effects of Immune Checkpoint Inhibitors (Anti-PD-1, -PD-L1, and -CTLA4 Therapies). Management: Carefully consider the need for corticosteroids, at doses of a prednisone-equivalent of 10 mg or more per day, during the initiation of immune checkpoint inhibitor therapy. Use of corticosteroids to treat immune related adverse events is still recommended Risk D: Consider Therapy Modification
Indium 111 Capromab Pendetide: Coadministration of Corticosteroids (Systemic) and Indium 111 Capromab Pendetide may alter diagnostic results. Risk X: Avoid
Inebilizumab: Corticosteroids (Systemic) may increase immunosuppressive effects of Inebilizumab. Risk C: Monitor
Influenza Virus Vaccines: Corticosteroids (Systemic) may decrease therapeutic effects of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiation of systemic corticosteroids at immunosuppressive doses. Influenza vaccines administered less than 14 days prior to or during such therapy should be repeated 3 months after therapy. Risk D: Consider Therapy Modification
Isoniazid: Corticosteroids (Systemic) may decrease serum concentration of Isoniazid. Risk C: Monitor
Leflunomide: Corticosteroids (Systemic) may increase immunosuppressive effects of Leflunomide. Management: Increase the frequency of chronic monitoring of platelet, white blood cell count, and hemoglobin or hematocrit to monthly, instead of every 6 to 8 weeks, if leflunomide is coadministered with immunosuppressive agents, such as systemic corticosteroids. Risk D: Consider Therapy Modification
Licorice: May increase serum concentration of Corticosteroids (Systemic). Risk C: Monitor
Loop Diuretics: Corticosteroids (Systemic) may increase hypokalemic effects of Loop Diuretics. Risk C: Monitor
Lutetium Lu 177 Dotatate: Corticosteroids (Systemic) may decrease therapeutic effects of Lutetium Lu 177 Dotatate. Management: Avoid repeated use of high-doses of corticosteroids during treatment with lutetium Lu 177 dotatate. Use of corticosteroids is still permitted for the treatment of neuroendocrine hormonal crisis. The effects of lower corticosteroid doses is unknown. Risk D: Consider Therapy Modification
Macimorelin: Coadministration of Corticosteroids (Systemic) and Macimorelin may alter diagnostic results. Risk X: Avoid
MetyraPONE: Coadministration of Corticosteroids (Systemic) and MetyraPONE may alter diagnostic results. Management: Consider alternatives to the use of the metyrapone test in patients taking systemic corticosteroids. Risk D: Consider Therapy Modification
Mifamurtide: Corticosteroids (Systemic) may decrease therapeutic effects of Mifamurtide. Risk X: Avoid
MiFEPRIStone: May decrease therapeutic effects of Corticosteroids (Systemic). MiFEPRIStone may increase serum concentration of Corticosteroids (Systemic). Management: Avoid mifepristone in patients who require long-term corticosteroid treatment of serious illnesses or conditions (eg, for immunosuppression following transplantation). Corticosteroid effects may be reduced by mifepristone treatment. Risk X: Avoid
Mumps- Rubella- or Varicella-Containing Live Vaccines: Corticosteroids (Systemic) may decrease therapeutic effects of Mumps- Rubella- or Varicella-Containing Live Vaccines. Corticosteroids (Systemic) may increase adverse/toxic effects of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Nadofaragene Firadenovec: Corticosteroids (Systemic) may increase adverse/toxic effects of Nadofaragene Firadenovec. Specifically, the risk of disseminated adenovirus infection may be increased. Risk X: Avoid
Natalizumab: Corticosteroids (Systemic) may increase immunosuppressive effects of Natalizumab. Risk X: Avoid
Neuromuscular-Blocking Agents (Nondepolarizing): May increase adverse neuromuscular effects of Corticosteroids (Systemic). Increased muscle weakness, possibly progressing to polyneuropathies and myopathies, may occur. Management: If concomitant therapy is required, use the lowest dose for the shortest duration to limit the risk of myopathy or neuropathy. Monitor for new onset or worsening muscle weakness, reduction or loss of deep tendon reflexes, and peripheral sensory decriments Risk D: Consider Therapy Modification
Nicorandil: Corticosteroids (Systemic) may increase adverse/toxic effects of Nicorandil. Gastrointestinal perforation has been reported in association with this combination. Risk C: Monitor
Nirmatrelvir and Ritonavir: May increase serum concentration of Triamcinolone (Systemic). Risk C: Monitor
Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective): Corticosteroids (Systemic) may increase adverse/toxic effects of Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective). Risk C: Monitor
Nonsteroidal Anti-Inflammatory Agents (Nonselective): Corticosteroids (Systemic) may increase adverse/toxic effects of Nonsteroidal Anti-Inflammatory Agents (Nonselective). Risk C: Monitor
Nonsteroidal Anti-Inflammatory Agents (Topical): May increase adverse/toxic effects of Corticosteroids (Systemic). Specifically, the risk of gastrointestinal bleeding, ulceration, and perforation may be increased. Risk C: Monitor
Ocrelizumab: Corticosteroids (Systemic) may increase immunosuppressive effects of Ocrelizumab. Risk C: Monitor
Ofatumumab: Corticosteroids (Systemic) may increase immunosuppressive effects of Ofatumumab. Risk C: Monitor
Ozanimod: Corticosteroids (Systemic) may increase immunosuppressive effects of Ozanimod. Risk C: Monitor
Pidotimod: Corticosteroids (Systemic) may decrease therapeutic effects of Pidotimod. Risk C: Monitor
Pimecrolimus: May increase immunosuppressive effects of Corticosteroids (Systemic). Risk X: Avoid
Pneumococcal Vaccines: Corticosteroids (Systemic) may decrease therapeutic effects of Pneumococcal Vaccines. Risk C: Monitor
Poliovirus Vaccine (Live/Trivalent/Oral): Corticosteroids (Systemic) may decrease therapeutic effects of Poliovirus Vaccine (Live/Trivalent/Oral). Corticosteroids (Systemic) may increase adverse/toxic effects of Poliovirus Vaccine (Live/Trivalent/Oral). Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Polymethylmethacrylate: Corticosteroids (Systemic) may increase adverse/toxic effects of Polymethylmethacrylate. Specifically, the risk for hypersensitivity or implant clearance may be increased. Management: Use caution when considering use of bovine collagen-containing implants such as the polymethylmethacrylate-based Bellafill brand implant in patients who are receiving immunosuppressants. Consider use of additional skin tests prior to administration. Risk D: Consider Therapy Modification
Quinolones: Corticosteroids (Systemic) may increase adverse/toxic effects of Quinolones. Specifically, the risk of tendonitis and tendon rupture may be increased. Risk C: Monitor
Rabies Vaccine: Corticosteroids (Systemic) may decrease therapeutic effects of Rabies Vaccine. Management: Complete rabies vaccination at least 2 weeks before initiation of immunosuppressant therapy if possible. If combined, check for rabies antibody titers, and if vaccination is for post exposure prophylaxis, administer a 5th dose of the vaccine. Risk D: Consider Therapy Modification
Ritlecitinib: Corticosteroids (Systemic) may increase immunosuppressive effects of Ritlecitinib. Risk X: Avoid
Ritodrine: Corticosteroids (Systemic) may increase adverse/toxic effects of Ritodrine. Risk C: Monitor
Ruxolitinib (Topical): Corticosteroids (Systemic) may increase immunosuppressive effects of Ruxolitinib (Topical). Risk X: Avoid
Salicylates: May increase adverse/toxic effects of Corticosteroids (Systemic). These specifically include gastrointestinal ulceration and bleeding. Corticosteroids (Systemic) may decrease serum concentration of Salicylates. Withdrawal of corticosteroids may result in salicylate toxicity. Risk C: Monitor
Sargramostim: Corticosteroids (Systemic) may increase therapeutic effects of Sargramostim. Specifically, corticosteroids may enhance the myeloproliferative effects of sargramostim. Risk C: Monitor
Sipuleucel-T: Corticosteroids (Systemic) may decrease therapeutic effects of Sipuleucel-T. Management: Consider reducing the dose or discontinuing immunosuppressants, such as systemic corticosteroids, prior to initiating sipuleucel-T therapy. Doses equivalent to more than 2 mg/kg or 20 mg/day of prednisone given for 2 or more weeks are immunosuppressive. Risk D: Consider Therapy Modification
Sitafloxacin: Corticosteroids (Systemic) may increase adverse/toxic effects of Sitafloxacin. Specifically, the risk of tendonitis and tendon rupture may be increased. Management: Consider alternatives to coadministration of corticosteroids and sitafloxacin unless the benefits of coadministration outweigh the risk of tendon disorders. Risk D: Consider Therapy Modification
Sodium Benzoate: Corticosteroids (Systemic) may decrease therapeutic effects of Sodium Benzoate. Risk C: Monitor
Sphingosine 1-Phosphate (S1P) Receptor Modulators: May increase immunosuppressive effects of Corticosteroids (Systemic). Risk C: Monitor
Succinylcholine: Corticosteroids (Systemic) may increase neuromuscular-blocking effects of Succinylcholine. Risk C: Monitor
Tacrolimus (Systemic): Corticosteroids (Systemic) may decrease serum concentration of Tacrolimus (Systemic). Conversely, when discontinuing corticosteroid therapy, tacrolimus concentrations may increase. Risk C: Monitor
Tacrolimus (Topical): Corticosteroids (Systemic) may increase immunosuppressive effects of Tacrolimus (Topical). Risk X: Avoid
Talimogene Laherparepvec: Corticosteroids (Systemic) may increase adverse/toxic effects of Talimogene Laherparepvec. Specifically, the risk of infection from the live, attenuated herpes simplex virus contained in talimogene laherparepvec may be increased. Risk X: Avoid
Tertomotide: Corticosteroids (Systemic) may decrease therapeutic effects of Tertomotide. Risk X: Avoid
Thiazide and Thiazide-Like Diuretics: Corticosteroids (Systemic) may increase hypokalemic effects of Thiazide and Thiazide-Like Diuretics. Risk C: Monitor
Tofacitinib: Corticosteroids (Systemic) may increase immunosuppressive effects of Tofacitinib. Management: Coadministration of tofacitinib with potent immunosuppressants is not recommended. Doses equivalent to more than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks are considered immunosuppressive. Risk D: Consider Therapy Modification
Typhoid Vaccine: Corticosteroids (Systemic) may decrease therapeutic effects of Typhoid Vaccine. Corticosteroids (Systemic) may increase adverse/toxic effects of Typhoid Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid
Ublituximab: Corticosteroids (Systemic) may increase immunosuppressive effects of Ublituximab. Risk C: Monitor
Upadacitinib: Corticosteroids (Systemic) may increase immunosuppressive effects of Upadacitinib. Management: Coadministration of upadacitinib with systemic corticosteroids at doses equivalent to greater than 2 mg/kg or 20 mg/day of prednisone (for persons over 10 kg) administered for 2 or more weeks is not recommended. Risk D: Consider Therapy Modification
Urea Cycle Disorder Agents: Corticosteroids (Systemic) may decrease therapeutic effects of Urea Cycle Disorder Agents. More specifically, Corticosteroids (Systemic) may increase protein catabolism and plasma ammonia concentrations, thereby increasing the doses of Urea Cycle Disorder Agents needed to maintain these concentrations in the target range. Risk C: Monitor
Vaccines (Live): Corticosteroids (Systemic) may increase adverse/toxic effects of Vaccines (Live). Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may decrease therapeutic effects of Vaccines (Live). Management: Avoid live vaccines during and for 1 month after therapy with immunosuppressive doses of corticosteroids (equivalent to prednisone > 2 mg/kg or 20 mg/day in persons over 10 kg for at least 2 weeks). Give live vaccines 4 weeks prior to therapy if possible. Risk D: Consider Therapy Modification
Vaccines (Non-Live/Inactivated/Non-Replicating): Corticosteroids (Systemic) may decrease therapeutic effects of Vaccines (Non-Live/Inactivated/Non-Replicating). Management: Administer vaccines at least 2 weeks prior to immunosuppressive corticosteroids if possible. If patients are vaccinated less than 14 days prior to or during such therapy, repeat vaccination at least 3 months after therapy if immunocompetence restored. Risk D: Consider Therapy Modification
Vitamin K Antagonists: Corticosteroids (Systemic) may increase anticoagulant effects of Vitamin K Antagonists. Risk C: Monitor
Yellow Fever Vaccine: Corticosteroids (Systemic) may increase adverse/toxic effects of Yellow Fever Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may decrease therapeutic effects of Yellow Fever Vaccine. Risk X: Avoid
Zoster Vaccine (Live/Attenuated): Corticosteroids (Systemic) may increase adverse/toxic effects of Zoster Vaccine (Live/Attenuated). Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may decrease therapeutic effects of Zoster Vaccine (Live/Attenuated). Risk X: Avoid
Some studies have shown an association between first trimester systemic corticosteroid use and oral clefts; however, information is conflicting and may be influenced by maternal dose, duration/frequency of exposure, and indication for use. Additional data are needed to evaluate any potential risk of systemic corticosteroids and other adverse pregnancy outcomes (eg, gestational diabetes mellitus, low-birth-weight, preeclampsia, preterm birth) (ACOG 2019; Bandoli 2017; Lunghi 2010; Skuladottir 2014). Hypoadrenalism may occur in newborns following maternal use of corticosteroids in pregnancy; monitor.
Triamcinolone is classified as a fluorinated corticosteroid. When systemic corticosteroids are needed in pregnancy for rheumatic disorders, nonfluorinated corticosteroids (eg, prednisone) are preferred. Chronic high doses should be avoided (ACR [Sammaritano 2020]).
Triamcinolone may be present in breast milk (may be dose dependent).
Data related to the presence of triamcinolone in breast milk are available from a patient treated for granulomatous mastitis. Triamcinolone 120 mg was injected into the left breast at 7 months postpartum. The patient pumped the left breast and the infant was breastfed from the right. Breast milk samples were obtained from the left breast at 0, 14, 73, 144, and 169 hours after the injection. Triamcinolone concentrations in breast milk were 24.9 ng/mL (14 hours), 2.11 ng/mL (73 hours), and <0.78 ng/mL for the remaining samples. Using a milk concentration of 24.9 ng/mL, authors of the study calculated the estimated infant dose of triamcinolone via breast milk to be 0.003735 mg/kg/day providing a relative infant dose (RID) of 0.23% compared to the maternal dose of 1.6 mg/kg. The oral bioavailability of triamcinolone is low, which would also limit potential infant absorption (Mitchell 2024). In general, breastfeeding is considered acceptable when the RID of a medication is <10% (Anderson 2016; Ito 2000). Triamcinolone was not detected in the breast milk of a second patient also treated for granulomatous mastitis. Triamcinolone 40 mg was injected into the affected breast and breast milk was collected 1 and 4 hours after the injection, then once daily for 1 week. Triamcinolone was not present in any of the breast milk samples (Rosen-Carole 2023).
A case report notes a decrease in milk production following high-dose cervical and epidural triamcinolone injections in a breastfeeding mother with a previously abundant milk supply (McGuire 2012). Decreased milk production on the side of injection was noted following triamcinolone injections directly into the breasts of lactating patients for the treatment of idiopathic granulomatous mastitis (Kornfeld 2021; Rosen-Carole 2023).
According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and the benefits of treatment to the mother. Corticosteroids are generally considered compatible with breastfeeding when used in usual doses; however, monitoring of the breastfeeding infant for adverse reactions is recommended (WHO 2002). Triamcinolone is classified as a fluorinated corticosteroid. When systemic corticosteroids are needed in a lactating patient for rheumatic disorders, low doses of nonfluorinated corticosteroids (eg, prednisone) are preferred (ACR [Sammaritano 2020]).
Ensure adequate intake of calcium and vitamins (or consider supplementation) in patients on medium-to-high doses of systemic corticosteroids.
Blood pressure, blood glucose, electrolytes; weight; intraocular pressure (use >6 weeks); bone mineral density; growth and development in children; HPA axis suppression; screen for hepatitis B prior to initiation; latent or active amebiasis prior to initiation in patients who have spent time in tropical climates or have unexplained diarrhea; reactivation of tuberculosis in patients with latent tuberculosis or tuberculin reactivity; signs and symptoms of infection.
A long acting corticosteroid with minimal sodium-retaining potential. Decreases inflammation by suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability; suppresses the immune system by reducing activity and volume of the lymphatic system; suppresses adrenal function at high doses
Onset: Adrenal suppression: IM (acetonide): 24 to 48 hours; Intra-articular: >24 hours
Duration: Adrenal suppression: IM (acetonide): 30 to 40 days; Intra-articular: 28 to 42 days
Distribution: Vd: IV (acetonide): 99.5 L
Metabolism: Hepatic (Asare 2007)
Half-life elimination: Plasma: 300 minutes (Asare 2007)
Excretion: Urine (75% primarily); bile and feces (25%) (Asare 2007)
