Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Suspension, Intraocular, as acetonide:
Triesence: 40 mg/mL (1 mL) [contains polysorbate 80]
Pharmacology
Mechanism of Action
Suppresses the immune system by reducing activity and volume of the lymphatic system
Pharmacokinetics/Pharmacodynamics
Half-Life Elimination
Intravitreal: Nonvitrectomized patients: 18.7 ± 5.7 days; Vitrectomized patients: ~3.2 days (based upon 1 patient)
Use: Labeled Indications
Ocular disease: Treatment of sympathetic ophthalmia, temporal arteritis, uveitis, ocular inflammatory conditions unresponsive to topical corticosteroids
Vitrectomy visualization: Visualization during vitrectomy
Contraindications
Hypersensitivity to triamcinolone or any component of the formulation; systemic fungal infections
Canadian labeling: Additional contraindications (not in US labeling): Active or suspected ocular herpes simplex
Dosage and Administration
Dosing: Adult
Ocular disease: Intravitreal: Initial: 4 mg as a single dose; additional doses may be given as needed
Visualization during vitrectomy: Intravitreal: 1 to 4 mg
Dosing: Geriatric
Refer to adult dosing.
Dosing: Pediatric
Ocular disease: Infants, Children, and Adolescents: Intravitreal: Initial: 4 mg as a single dose; additional doses may be given as needed over the course of treatment
Visualization during vitrectomy: Infants, Children, and Adolescents: Intravitreal: Initial: 1 to 4 mg
Reconstitution
Vitrectomy: May be diluted with sterile irrigating solution (eg, BSS Sterile Irrigating Solution) prior use. Range of dilution is typically 1:10 to 1: 20. In a clinical study, a 2 mg/mL was administered by diluting 0.05 mL of triamcinolone in 0.95 mL of sterile irrigating solution (Triesence Canadian product labeling 2016).
Administration
For intravitreal administration only; do not administer IV. Administer under controlled aseptic conditions (eg, sterile gloves, sterile drape, sterile eyelid speculum). Shake vial vigorously for 10 seconds before withdrawing dose; do not use if agglomerated (clumpy or granular appearance); inject immediately after suspension is withdrawn from the vial. Adequate anesthesia and a broad-spectrum bactericidal agent should be administered prior to injection. If administration is required in the second eye, a new vial/syringe should be used.
Storage
Store at 4°C to 25°C (39°F to 77°F); do not freeze. Protect from light.
Drug Interactions
Nonsteroidal Anti-Inflammatory Agents (Ophthalmic): May enhance the adverse/toxic effect of Corticosteroids (Ophthalmic). Healing of ophthalmic tissue during concomitant administration of ophthalmic products may be delayed. Monitor therapy
Ritodrine: Corticosteroids may enhance the adverse/toxic effect of Ritodrine. Monitor therapy
Adverse Reactions
>10%: Ophthalmic: Increased intraocular pressure (20% to 60%), progression of cataract (20% to 60%)
1% to 10%: Ophthalmic: Blurred vision (≤2%), conjunctival hemorrhage (≤2%), decreased visual acuity (≤2%), endophthalmitis (≤2%), eye discomfort (transient) (≤2%), glaucoma (≤2%), hypopyon (≤2%), ophthalmic inflammation (≤2%), optic disc disorder (vascular disorder: ≤2%), retinal detachment (≤2%), vitreous opacity (≤2%)
<1%, postmarketing, and/or case reports: Exophthalmos
Warnings/Precautions
Concerns related to adverse effects:
- Adrenal suppression: Prolonged use 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.
- Hypersensitivity: Rare cases of anaphylactoid reactions have been observed in patients receiving corticosteroids.
- Immunosuppression: Prolonged use may increase the incidence of secondary infection, mask acute infection (including fungal infections), prolong or exacerbate viral infections, or limit response to killed or inactivated vaccines. Exposure to chickenpox or measles should be avoided. Close observation is required in patients with latent tuberculosis and/or TB reactivity; restrict use in active TB (only fulminating or disseminated TB in conjunction with antituberculosis treatment). Amebiasis should be ruled out in any patient with recent travel to tropic climates or unexplained diarrhea prior to initiation of corticosteroids. Use with caution in patients with threadworm infection; may cause serious hyperinfection. Use with extreme caution in patients with Strongyloides infections; hyperinfection, dissemination and fatalities have occurred.
- Kaposi sarcoma: Prolonged treatment with corticosteroids has been associated with the development of Kaposi's sarcoma (case reports); if noted, discontinuation of therapy should be considered (Goedert 2002).
- Myopathy: Acute myopathy has been reported with high-dose corticosteroids, usually in patients with neuromuscular transmission disorders; may involve ocular and/or respiratory muscles.
- Psychiatric disturbances: Corticosteroid use may cause psychiatric disturbances, including euphoria, insomnia, mood swings, and personality changes, and severe depression to psychotic manifestations. Preexisting psychiatric conditions may be exacerbated by corticosteroid use.
Disease-related concerns:
- Cardiovascular disease: Use with caution in patients with HF and/or hypertension; corticosteroids have 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.
- GI disease: Use with caution in patients with GI diseases (diverticulitis, fresh intestinal anastomoses, active or latent peptic ulcer, abscess or other pyogenic infection) due to perforation risk.
- Myasthenia gravis: Use with caution in patients with myasthenia gravis; exacerbation of symptoms has occurred, especially during initial treatment with corticosteroids.
- Ocular disease: Use with caution in patients with cataracts and/or glaucoma; elevated intraocular pressure may occur with effects lasting up to 6 months following injection. Use has also been associated with endophthalmitis and cataracts, particularly posterior subcapsular cataracts. Consider routine eye exams in chronic users.
- Osteoporosis: Use with caution in patients with osteoporosis; corticosteroids have been associated with increased bone loss and osteoporotic fractures.
- Renal impairment: Use with caution in patients with renal impairment.
- Thyroid disease: Use with caution in patients with thyroid disease; metabolic clearance of corticosteroids increases in hyperthyroid patients and decreases in hypothyroid patients.
Special populations:
- Pediatric: May affect growth velocity; growth should be routinely monitored in pediatric patients.
Dosage form specific issues:
- 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 use: For ophthalmic use only; do not administer IV.
Monitoring Parameters
Following injection, monitor for increased intraocular pressure and endophthalmitis; check for perfusion of optic nerve head immediately after injection, tonometry within 30 minutes, biomicroscopy between 2 to 7 days after injection.
Pregnancy
Pregnancy Risk Factor
D
Pregnancy Considerations
Adverse events were have been observed in animal reproduction studies. Some studies have shown an association between first trimester corticosteroid use and oral clefts, intrauterine growth restriction, and decreased birth weight. The amount of triamcinolone absorbed systemically following ophthalmic administration is not known. Use of intravitreal triamcinolone in pregnancy has been noted in case reports (Errera 2013; Fazelat 2011).
Patient Education
- Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
- Patient may experience blurred vision. Have patient report immediately to prescriber floaters, vision changes, eye pain, or severe eye irritation (HCAHPS).
- Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.
