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Triamcinolone


Pronunciation

 (trye am SIN oh lone)


U.S. Brand Names

 Aristocort®; Aristocort® A; Aristocort® Forte; Aristospan®; Azmacort®; Kenalog®; Kenalog-10®; Kenalog-40®; Kenalog® in Orabase®; Nasacort® [HFA]; Nasacort® AQ; Triderm®; Tri-Nasal®


Synonyms

 Triamcinolone Acetonide, Aerosol; Triamcinolone Acetonide, Parenteral; Triamcinolone Diacetate, Oral; Triamcinolone Diacetate, Parenteral; Triamcinolone Hexacetonide; Triamcinolone, Oral


Generic Available

 Yes: Cream, lotion, ointment, paste


Canadian Brand Names

 Aristocort®; Aristospan®; Azmacort®; Kenalog®; Kenalog® in Orabase; Nasacort® AQ; Oracort; Triaderm; Trinasal®


Use

Nasal inhalation: Management of seasonal and perennial allergic rhinitis in patients 6 years of age

Oral inhalation: Control of bronchial asthma and related bronchospastic conditions

Oral topical: Adjunctive treatment and temporary relief of symptoms associated with oral inflammatory lesions and ulcerative lesions resulting from trauma

Systemic: Adrenocortical insufficiency, rheumatic disorders, allergic states, respiratory diseases, systemic lupus erythematosus (SLE), and other diseases requiring anti-inflammatory or immunosuppressive effects

Topical: Inflammatory dermatoses responsive to steroids


Use - Dental

 Oral, topical: Adjunctive treatment and temporary relief of symptoms associated with oral inflammatory lesions and ulcerative lesions resulting from trauma


Pregnancy Risk Factor

 C


Pregnancy Implications

 There are no adequate and well-controlled studies in pregnant women, however, triamcinolone is teratogenic in animals; use during pregnancy with caution. Increased incidence of cleft palate, neonatal adrenal suppression, low birth weight, and cataracts in the infant has been reported following corticosteroid use during pregnancy. In general, the use of large amounts, or prolonged use, of topical corticosteroids during pregnancy should be avoided. In the mother, corticosteroids may increase calcium and potassium excretion, elevate blood pressure, and cause salt and water retention.


Lactation

 Excretion in breast milk unknown/use caution


Contraindications

 Hypersensitivity to triamcinolone or any component of the formulation; systemic fungal infections; serious infections (except septic shock or tuberculous meningitis); primary treatment of status asthmaticus; fungal, viral, or bacterial infections of the mouth or throat (oral topical formulation)


Warnings/Precautions

 May cause suppression of hypothalamic-pituitary-adrenal (HPA) axis, particularly in younger children or in patients receiving high doses for prolonged periods. 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. 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. Withdrawal and discontinuation of the corticosteroid should be done slowly and carefully

Use with caution in patients with hypothyroidism, cirrhosis, nonspecific ulcerative colitis and patients at increased risk for peptic ulcer disease. Corticosteroids should be used with caution in patients with diabetes, hypertension, osteoporosis, glaucoma, cataracts, or tuberculosis. Use caution in hepatic impairment. Do not use occlusive dressings on weeping or exudative lesions and general caution with occlusive dressings should be observed; discontinue if skin irritation or contact dermatitis should occur; do not use in patients with decreased skin circulation; avoid the use of high potency steroids on the face.

Because of the risk of adverse effects, systemic corticosteroids should be used cautiously in the elderly, in the smallest possible dose, and for the shortest possible time. Azmacort® (metered dose inhaler) comes with its own spacer device attached and may be easier to use in older patients.

Controlled clinical studies have shown that orally-inhaled and intranasal corticosteroids may cause a reduction in growth velocity in pediatric patients. (In studies of orally-inhaled corticosteroids, the mean reduction in growth velocity was approximately 1 centimeter per year [range 0.3-1.8 cm per year] and appears to be related to dose and duration of exposure.) The growth of pediatric patients receiving inhaled corticosteroids, should be monitored routinely (eg, via stadiometry). To minimize the systemic effects of orally-inhaled and intranasal corticosteroids, each patient should be titrated to the lowest effective dose.

May suppress the immune system, patients may be more susceptible to infection. Use with caution in patients with systemic infections or ocular herpes simplex. Avoid exposure to chickenpox and measles.

Oral topical: Discontinue if local irritation or sensitization should develop. If significant regeneration or repair of oral tissues has not occurred in seven days, re-evaluation of the etiology of the oral lesion is advised.


Adverse Reactions

Systemic: Frequency not defined:

Cardiovascular: CHF, hypertension

Central nervous system: Convulsions, fever, headache, intracranial pressure increased, vertigo

Dermatologic: Bruising, facial erythema, petechiae, photosensitivity, rash, thin/fragile skin, wound healing impaired

Endocrine & metabolic: Adrenocortical/pituitary unresponsiveness (particularly during stress), carbohydrate tolerance decreased, cushingoid state, diabetes mellitus (manifestations of latent disease), fluid retention, growth suppression (children), hypokalemic alkalosis, menstrual irregularities, negative nitrogen balance, potassium loss, sodium retention

Gastrointestinal: Abdominal distention, diarrhea, dyspepsia, nausea, oral Monilia (oral inhaler), pancreatitis, peptic ulcer, ulcerative esophagitis, weight gain

Local: Skin atrophy (at the injection site)

Neuromuscular & skeletal: Femoral/humeral head aseptic necrosis, muscle mass decreased, muscle weakness, osteoporosis, pathologic fracture of long bones, steroid myopathy, vertebral compression fractures

Ocular: Cataracts, intraocular pressure increased, exophthalmos, glaucoma

Respiratory: Cough increased (nasal spray), epistaxis (nasal inhaler/spray), pharyngitis (nasal spray/oral inhaler), sinusitis (oral inhaler), voice alteration (oral inhaler)

Miscellaneous: Anaphylaxis, diaphoresis increased, suppression to skin tests

Topical: Frequency not defined:

Dermatologic: Itching, allergic contact dermatitis, dryness, folliculitis, skin infection (secondary), itching, hypertrichosis, acneiform eruptions, hypopigmentation, skin maceration, skin atrophy, striae, miliaria, perioral dermatitis, atrophy of oral mucosa

Local: Burning, irritation


Overdosage/Toxicology

 When consumed in high doses for prolonged periods, systemic hypercorticism and adrenal suppression may occur. In those cases, discontinuation of the corticosteroid should be done judiciously.


Drug Interactions

Decreased effect: Barbiturates, phenytoin, rifampin increase metabolism of triamcinolone; vaccine and toxoid effects may be reduced

Increased effect: Salmeterol: The addition of salmeterol has been demonstrated to improve response to inhaled corticosteroids (as compared to increasing steroid dosage).

Increased toxicity: Salicylates may increase risk of GI ulceration


Ethanol/Nutrition/Herb Interactions

Ethanol: Avoid ethanol (may enhance gastric mucosal irritation).

Food: Triamcinolone interferes with calcium absorption.

Herb/Nutraceutical: Avoid cat's claw, echinacea (have immunostimulant properties).


Stability

 Store at room temperature; avoid freezing

Injection, suspension: Shake well prior to use

Diacetate suspension: May dilute prior to use using NS or equal parts of NS and procaine 1%. Diluted suspension stable ~1 week. Avoid diluents containing parabens or preservatives (may cause flocculation). Suspensions for intralesional use may be diluted to 1:1 or 1:10 concentration.

Hexacetonide suspension: Avoid diluents containing parabens or preservatives (may cause flocculation). Diluted suspension stable ~1 week. Suspension for intralesional use, may be diluted with D5NS, D10NS or SWFI to a 1:1, 1:2, or 1:4 concentration. Solutions for intra-articular use, may be diluted with lidocaine 1% or 2%.

Topical spray: Avoid excessive heat


Mechanism of Action

 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


Pharmacodynamics/Kinetics

Duration: Oral: 8-12 hours

Absorption: Topical: Systemic

Time to peak: I.M.: 8-10 hours

Half-life elimination: Biologic: 18-36 hours


Dosage

 The lowest possible dose should be used to control the condition; when dose reduction is possible, the dose should be reduced gradually. Parenteral dose is usually 1 /3 to 1 /2 the oral dose given every 12 hours. In life-threatening situations, parenteral doses larger than the oral dose may be needed.

Injection:

Acetonide:

Intra-articular, intrabursal, tendon sheaths: Adults: Initial: Smaller joints: 2.5-5 mg, larger joints: 5-15 mg

Intradermal: Adults: Initial: 1 mg

I.M.: Range: 2.5-60 mg/day

Children 6-12 years: Initial: 40 mg

Children >12 years and Adults: Initial: 60 mg

Diacetate: Adults:

Intra-articular, Intrasynovial: Range: 5-40 mg; duration of effect varies from 1 week to 2 months, although more frequent dosing may be needed in acutely-inflamed joints

Average dose: Knee: 25 mg, finger: 2-5 mg

Intralesional, sublesional: Range: 5-48 mg, dependent upon size of lesion

Maximum: 12.5 mg/injection site, 25 mg/lesion, 75 mg/week

Usual treatment course: 2-3 injections at 1- to 2-week intervals

I.M.: Initial range: 3-48 mg/day; average dose: 40 mg/week

Hexacetonide: Adults:

Intralesional, sublesional: Up to 0.5 mg/square inch of affected skin

Intra-articular: Range: 2-20 mg


Intranasal:

Triamcinolone Dosing

  Acetonide Diacetate Hexacetonide
Intrasynovial 2.5-40 mg 5-40 mg  
Intralesional 1-30 mg (usually 1 mg per injection site); 10 mg/mL suspension usually used 5-48 mg
(not >25 mg per lesion)		 Up to 0.5 mg/sq inch affected area
Sublesional 1-30 mg
Systemic I.M. 2.5-60 mg/dose
(usual adult dose: 60 mg; may repeat with 20-100 mg dose when symptoms recur)		 ~40 mg/wk  
Intra-articular 2.5-40 mg 2-40 mg 2-20 mg average
large joints 5-15 mg   10-20 mg
small joints 2.5-5 mg   2-6 mg
Tendon sheaths 2.5-10 mg    
Intradermal 1 mg/site    

Intranasal: Perennial allergic rhinitis, seasonal allergic rhinitis:

Nasal spray:

Children 6-11 years: 110 mcg/day as 1 spray in each nostril once daily.

Children 12 years and Adults: 220 mcg/day as 2 sprays in each nostril once daily

Nasal inhaler:

Children 6-11 years: Initial: 220 mcg/day as 2 sprays in each nostril once daily

Children 12 years and Adults: Initial: 220 mcg/day as 2 sprays in each nostril once daily; may increase dose to 440 mcg/day (given once daily or divided and given 2 or 4 times/day)

Oral: Adults:

Acute rheumatic carditis: Initial: 20-60 mg/day; reduce dose during maintenance therapy

Acute seasonal or perennial allergic rhinitis: 8-12 mg/day

Adrenocortical insufficiency: Range 4-12 mg/day

Bronchial asthma: 8-16 mg/day

Dermatological disorders, contact/atopic dermatitis: Initial: 8-16 mg/day

Ophthalmic disorders: 12-40 mg/day

Rheumatic disorders: Range: 8-16 mg/day

SLE: Initial: 20-32 mg/day, some patients may need initial doses 48 mg; reduce dose during maintenance therapy

Oral inhalation: Asthma:

Children 6-12 years: 100-200 mcg 3-4 times/day or 200-400 mcg twice daily; maximum dose: 1200 mg/day

Children >12 years and Adults: 200 mcg 3-4 times/day or 400 mcg twice daily; maximum dose: 1600 mcg/day

Oral topical: Oral inflammatory lesions/ulcers: Press a small dab (about 1 /4 inch) to the lesion until a thin film develops. A larger quantity may be required for coverage of some lesions. For optimal results use only enough to coat the lesion with a thin film; do not rub in.

Topical:

Cream, Ointment: Apply thin film to affected areas 2-4 times/day

Spray: Apply to affected area 3-4 times/day


Administration

Injection: Avoid injecting into a previously infected joint; do not inject into unstable joints

I.M.: Inject deep in large muscle mass, avoid deltoid.

SubQ: Avoid subcutaneous administration.

Nasal spray, inhalation: Shake well prior to use. Gently blow nose to clear nostrils.

Oral inhalation: Shake well prior to use. Rinse mouth and throat after using inhaler to prevent candidiasis. Use spacer device provided with Azmacort®.

Oral topical: Apply small dab to lesion until a thin film develops; do not rub in. Apply at bedtime or after meals if applications are needed throughout the day.

Tablet: Once-daily doses should be given in the morning.

Topical: Apply a thin film sparingly and avoid topical application on the face. Do not use on open skin or wounds. Do not occlude area unless directed.


Dietary Considerations

 May be taken with food to decrease GI distress.


Patient Education

 Take exactly as directed; do not increase dose or discontinue abruptly without consulting prescriber. Take oral medication with or after meals. Avoid alcohol. Limit intake of caffeine or stimulants. Prescriber may recommend increased dietary vitamins, minerals, or iron. If you have diabetes, monitor glucose levels closely (antidiabetic medication may need to be adjusted). Inform prescriber if you are experiencing greater than normal levels of stress (medication may need adjustment). Some forms of this medication may cause GI upset (oral medication may be taken with meals to reduce GI upset; or small, frequent meals and frequent mouth care may reduce GI upset). You may be more susceptible to infection (avoid crowds and exposure to infection). Report promptly excessive nervousness or sleep disturbances; any signs of infection (sore throat, unhealed injuries); excessive growth of body hair or loss of skin color; vision changes; excessive or sudden weight gain (>3 lb/week); swelling of face or extremities; respiratory difficulty; muscle weakness; change in color of stools (black or tarry) or persistent abdominal pain; or worsening of condition or failure to improve. Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to become pregnant. Consult prescriber if breast-feeding.

Aerosol: Shake gently before use. Use at regular intervals, no more frequently than directed. Not for use during acute asthmatic attack. Follow directions that accompany product. Rinse mouth and throat after use to prevent candidiasis. Do not use intranasal product if you have a nasal infection, nasal injury, or recent nasal surgery. If using two products, consult prescriber in which order to use the two products. Report unusual cough or spasm; persistent nasal bleeding, burning, or irritation; or worsening of condition.

Inhalation: Sit when using. Take deep breaths for 3-5 minutes, and clear nasal passages before administration (use decongestant as needed). Hold breath for 5-10 seconds after use, and wait 1-3 minutes between inhalations. Follow package insert instructions for use. Do not exceed maximum dosage. If also using inhaled bronchodilator, use before triamcinolone. Rinse mouth and throat after use to reduce aftertaste and prevent candidiasis.

Topical: For external use only. Not for eyes or mucous membranes or open wounds. Apply in very thin layer to occlusive dressing. Apply dressing to area being treated. Avoid prolonged or excessive use around sensitive tissues, genital, or rectal areas. Inform prescriber if condition worsens (swelling, redness, irritation, pain, open sores) or fails to improve.


Additional Information

 16 mg triamcinolone is equivalent to 100 mg cortisone (no mineralocorticoid activity).

Effects of inhaled/intranasal steroids on growth have been observed in the absence of laboratory evidence of HPA axis suppression, suggesting that growth velocity is a more sensitive indicator of systemic corticosteroid exposure in pediatric patients than some commonly used tests of HPA axis function. The long-term effects of this reduction in growth velocity associated with orally-inhaled and intranasal corticosteroids, including the impact on final adult height, are unknown. The potential for "catch up" growth following discontinuation of treatment with inhaled corticosteroids has not been adequately studied.


Anesthesia and Critical Care Concerns/Other Considerations

 Triamcinolone is a long-acting corticosteroid with minimal sodium-retaining potential.

Neuromuscular Effects: ICU-acquired paresis was recently studied in 5 ICUs (3 medical and 2 surgical ICUs) at 4 French hospitals. All ICU patients without pre-existing neuromuscular disease admitted from March 1999 through June 2000 were evaluated (De Jonghe B, 2002). Each patient had to be mechanically ventilated for 7 days and was screened daily for awakening. The first day the patient was considered awake was Study Day 1. Patients with severe muscle weakness on Study Day 7 were considered to have ICU-acquired paresis. Among the 95 patients who were evaluable, about 25% developed ICU-acquired paresis. Independent predictors included female gender, the number of days with 2 organ dysfunction, and administration of corticosteroids. Further studies may be required to verify and characterize the association between the development of ICU-acquired paresis and use of corticosteroids. Concurrent use of a corticosteroid and muscle relaxant appear to increase the risk of certain ICU myopathies; avoid or administer the corticosteroid at the lowest dose possible.

Adrenal Insufficiency: Patients will often have steroid-induced adverse effects on glucose tolerance and lipid profiles. When discontinuing steroid therapy in patients on long-term steroid supplementation, it is important that the steroid therapy be discontinued gradually. Abrupt withdrawal may result in adrenal insufficiency with hypotension and hyperkalemia. Patients on long-term steroid supplementation will require higher corticosteroid doses when subject to stress (ie, trauma, surgery, severe infection). Guidelines for glucocorticoid replacement during various surgical procedures have been published (Salem M, 1994, Coursin DB, 2002).

Septic Shock: A recent randomized, double-blind, placebo controlled trial assessed whether low dose corticosteroid administration could improve 28-day survival in patients with septic shock and relative adrenal insufficiency. Relative adrenal insufficiency was defined as an inappropriate response to corticotropin administration (increase of serum cortisol of 9 mcg/dL from baseline). Cortisol levels were drawn immediately before corticotropin administration and 30 to 60 minutes afterwards. Three hundred adult septic shock patients requiring mechanical ventilation and vasopressor support were randomized to either hydrocortisone (50 mg IVP every 6 hours) and fludrocortisone (50 mcg tablet daily via nasogastric tube) or matching placebos for 7 days. In patients who did not appropriately respond to corticotropin (nonresponders), there were significantly fewer deaths in the active treatment group. Vasopressor therapy was withdrawn more frequently in this subset of the active treatment group. Adverse events were similar in both groups. Patients who lack adrenal reserve and thus have relative adrenal insufficiency during the stress of septic shock may benefit from physiologic steroid replacement. However, there was a trend for increased mortality in patients who responded to the corticotropin test (increase serum cortisol >9 mcg/dL from baseline). These patients may not benefit from physiologic steroid replacement. Further study is required to better characterize the patient populations who may benefit.


Cardiovascular Considerations

 Inhaled steroid therapy, usually used for chronic obstructive lung disease, has the important advantage of having minimal systemic effects. The inhaled steroid, when administered appropriately, may be assumed to have pulmonary effects equivalent to about 10 mg of oral steroids but with minimal systemic consequences. Oral and intravenous steroid therapy in patients with heart failure should be administered cautiously with special attention given to signs and symptoms of fluid retention.


Dental Health: Effects on Dental Treatment

 Key adverse event(s) related to dental treatment: Ulcerative esophagitis, perioral dermatitis, atrophy of oral mucosa, burning, and irritation.


Dental Health: Vasoconstrictor/Local Anesthetic Precautions

 No information available to require special precautions


Mental Health: Effects on Mental Status

 Nervousness and insomnia are common; may cause drowsiness, delirium, euphoria, hallucinations, or mood swings


Mental Health: Effects on Psychiatric Treatment

 Barbiturates may increase the metabolism of triamcinolone


Dosage Forms

Aerosol for nasal inhalation, as acetonide [CFC free] (Nasacort® [HFA]): 55 mcg/inhalation (9.3 g) [100 doses]

Aerosol for nasal inhalation, as acetonide [spray]:

Nasacort® AQ: 55 mcg/inhalation (16.5 g) [120 doses]

Tri-Nasal®: 50 mcg/inhalation (15 mL) [120 doses]

Aerosol for oral inhalation, as acetonide (Azmacort®): 100 mcg per actuation (20 g) [240 actuations]

Aerosol, topical, as acetonide (Kenalog®): 0.2 mg/2-second spray (63 g)

Cream, as acetonide: 0.025% (15 g, 80 g); 0.1% (15 g, 80 g, 454 g, 2270 g); 0.5% (15 g)

Aristocort® A: 0.025% (15 g, 60 g); 0.1% (15 g, 60 g); 0.5% (15 g) [contains benzyl alcohol]

Kenalog®: 0.1% (15 g, 60 g, 80 g); 0.5% (20 g)

Triderm®: 0.1% (30 g, 85 g)

Injection, suspension, as acetonide:

Kenalog-10®: 10 mg/mL (5 mL) [contains benzyl alcohol; not for I.V. or I.M. use]

Kenalog-40®: 40 mg/mL (1 mL, 5 mL, 10 mL) [contains benzyl alcohol; not for I.V. or intradermal use]

Injection, suspension, as diacetate:

Aristocort®: 25 mg/mL (5 mL) [contains benzyl alcohol; not for I.V. use]

Aristocort® Forte: 40 mg/mL (1 mL, 5mL) [contains benzyl alcohol; not for I.V. use]

Injection, suspension, as hexacetonide (Aristospan®): 5 mg/mL (5 mL); 20 mg/mL (1 mL, 5 mL) [contains benzyl alcohol; not for I.V. use]

Lotion, as acetonide (Kenalog®): 0.025% (60 mL); 0.1% (60 mL)

Ointment, topical, as acetonide: 0.025% (80 g); 0.1% (15 g, 80 g, 454 g)

Aristocort® A, Kenalog®: 0.1% (15 g, 60 g)

Paste, oral, topical, as acetonide (Kenalog® in Orabase®): 0.1% (5 g)

Tablet (Aristocort®): 4 mg [contains lactose and sodium benzoate]


References

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Cooper MS and Stewart PM, "Corticosteroid Insufficiency in Acutely Ill Patients," N Engl J Med , 2003, 348(8):727-34.

Coursin DB and Wood KE, "Corticosteroid Supplementation for Adrenal Insufficiency," JAMA , 2002, 287(2):236-40.

de Jonghe B, Sharshar T, Lefaucheur JP, et al, "Paresis Acquired in the Intensive Care Unit. A Prospective Multicenter Study," JAMA , 2002, 288(22):2859-67.

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International Brand Names

 Aristocort® (CA); Aristospan® (CA); Azmacort® (CA, RU); Berlicort® (DE, RO, RU); Delphicort® (AT, DE); Ipercortis® (IT); Kenacort® (AR, BE, CH, CN, ID, IN, LU); Kenalog® (CA); Kenalog® in Orabase (CA); Ledercort® (AR, BE, ES, HK, IN, IT, LU); Nasacort® AQ (CA); Oracort (CA); Polcortolon® [compr.] (HU, PL, RU); Polcortolone® (RO); Rhinisan® (DE); Sedozolona® (AR); Shincort® (TH); Simacort® (TH); Sterocort® (IL); Triaderm (CA); Triamcinolona® (AR); Triamcinolone® (CY); Triamcort® [Tab.] (ID); Triam Oral® (DE); Triampoen® (AR); Triamsicort® (MX); Tricort® (CZ); Trinasal® (CA); Volon® (AT, DE)


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