Triamcinolone (nasal)

Triamcinolone (nasal)
Adult Indications & Dosage
Pediatric Indications & Dosage
Contraindications
Warnings & Precautions
Adverse Reactions
Drug Interactions
Use in Specific Populations
Administration & Monitoring
Overdosage
Pharmacology
Clinical Studies
How Supplied
Images
Patient Counseling Information
Precautions with Alcohol
Brand Names
Look-Alike Names

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Turky Alkathery, M.D. [2]

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Overview

Triamcinolone (nasal) is a corticosteroid that is FDA approved for the treatment of the nasal symptoms of seasonal and perennial allergic rhinitis in adults and children 2 years of age and older.. Common adverse reactions include pharyngitis, epistaxis, flu syndrome, cough increased, bronchitis, dyspepsia, tooth disorder, headache, pharyngolaryngeal pain, nasopharyngitis, abdominal upper pain, diarrhea, and excoriation.

Adult Indications and Dosage

FDA-Labeled Indications and Dosage (Adult)

Indications

Triamcinolone Acetonide Nasal Spray is indicated for the treatment of the nasal symptoms of seasonal and perennial allergic rhinitis in adults and children 2 years of age and older.

Dosage

Administer Triamcinolone Acetonide Nasal Spray by the intranasal route only. Shake Triamcinolone Acetonide Nasal Spray well before each use.

2.1 Adults and Adolescents 12 Years of Age and Older The recommended starting and maximum dose is 220 mcg per day as two sprays in each nostril once daily. Titrate an individual patient to the minimum effective dose to reduce the possibility of side effects. When the maximum benefit has been achieved and symptoms have been controlled, reducing the dose to 110 mcg per day (one spray in each nostril once a day) has been shown to be effective in maintaining control of the allergic rhinitis symptoms.

2.3 Administration Information Priming: Prime Triamcinolone Acetonide Nasal Spray before using for the first time by shaking the contents well and releasing 5 sprays into the air away from the face. It will remain adequately primed for two weeks. If the product is not used for more than 2 weeks, then it can be adequately reprimed with one spray. Shake Triamcinolone Acetonide Nasal Spray well before each use.

If adequate relief of symptoms has not been obtained after 3 weeks of treatment, Triamcinolone Acetonide Nasal Spray should be discontinued.

3 DOSAGE FORMS AND STRENGTHS Triamcinolone Acetonide Nasal Spray is a metered-dose pump spray containing the active ingredient triamcinolone acetonide. Each actuation delivers 55 mcg triamcinolone acetonide from the nasal actuator after an initial priming of 5 sprays. Each 16.5 gram bottle (120 actuations) contains 9.075 mg of triamcinolone acetonide. The bottle should be discarded when the labeled-number of actuations have been reached even though the bottle is not completely empty.

Off-Label Use and Dosage (Adult)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Triamcinolone (nasal) in adult patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Triamcinolone (nasal) in adult patients.

Pediatric Indications and Dosage

FDA-Labeled Indications and Dosage (Pediatric)

Indications

Triamcinolone Acetonide Nasal Spray is indicated for the treatment of the nasal symptoms of seasonal and perennial allergic rhinitis in adults and children 2 years of age and older.

Dosage

2.2 Children 2 to 12 Years of Age Children 6 to 12 years of age: The recommended starting dose is 110 mcg per day given as one spray in each nostril once daily. Children not responding adequately to 110 mcg per day may use 220 mcg (2 sprays in each nostril) once daily. Once symptoms have been controlled, the dosage may be decreased to 110 mcg once daily.

Children 2 to 5 years of age: The recommended and maximum dose is 110 mcg per day given as one spray in each nostril once daily.

Triamcinolone Acetonide Nasal Spray is not recommended for children under 2 years of age.

Off-Label Use and Dosage (Pediatric)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Triamcinolone (nasal) in pediatric patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Triamcinolone (nasal) in pediatric patients.

Contraindications

Triamcinolone Acetonide should not be administered to patients with a history of hypersensitivity to triamcinolone acetonide or to any of the other ingredients of this preparation.

Warnings

5.1 Local Nasal Effects Epistaxis: In clinical studies of 2 to 12 weeks duration, epistaxis was observed more frequently in patients treated with Triamcinolone Acetonide Nasal Spray than those who received placebo.

Nasal Septal Perforation: In clinical trials, nasal septum perforation was reported in one adult patient treated with Triamcinolone Acetonide Nasal Spray.

Candida Infection: In clinical studies with Triamcinolone Acetonide Nasal Spray, the development of localized infections of the nose and pharynx with Candida albicans has rarely occurred. When such an infection develops it may require treatment with appropriate local or systemic therapy and discontinuation of Triamcinolone Acetonide Nasal Spray. Therefore, patients using Triamcinolone Acetonide Nasal Spray over several months or longer should be examined periodically for evidence of Candida infection or other signs of adverse effects on the nasal mucosa.

Impaired Wound Healing: Because of the inhibitory effect of corticosteroids on wound healing, patients who have experienced recent nasal ulcers, surgery, or trauma should not use Triamcinolone Acetonide Nasal Spray until healing has occurred.

5.2 Glaucoma and Cataracts Nasal and inhaled corticosteroids may result in the development of glaucoma and/or cataracts. Therefore, close monitoring is warranted in patients with a change in vision or with a history of increased intraocular pressure, glaucoma and/or cataracts.

5.3 Immunosuppression Persons who are using drugs that suppress the immune system are more susceptible to infections than healthy individuals. Chickenpox and measles, for example, can have a more serious or even fatal course in susceptible children or adults using corticosteroids. In children or adults who have not had these diseases or have not been properly immunized, particular care should be taken to avoid exposure. How the dose, route, and duration of corticosteroid administration affect the risk of developing a disseminated infection is not known. The contribution of the underlying disease and/or prior corticosteroid treatment to the risk is also not known. If exposed to chickenpox, prophylaxis with varicella zoster immune globulin (VZIG) may be indicated. If exposed to measles, prophylaxis with pooled intramuscular immunoglobulin (IG) may be indicated. (See the respective package inserts for complete VZIG and IG prescribing information.) If chickenpox develops, treatment with antiviral agents may be considered.

Corticosteroids should be used with caution, if at all, in patients with active or quiescent tuberculosis infections of the respiratory tract; untreated local or systemic fungal or bacterial infections; systemic viral or parasitic infections, or ocular herpes simplex because of the potential for worsening of these infections.

5.4 Hypothalamic-Pituitary-Adrenal Axis Effects Hypercorticism and Adrenal Suppression: When intranasal steroids are used at higher than recommended dosages or in susceptible individuals at recommended dosages, systemic corticosteroid effects such as hypercorticism and adrenal suppression may appear. If such changes occur, the dosage of Triamcinolone Acetonide Nasal Spray should be discontinued slowly, consistent with accepted procedures for discontinuing oral corticosteroid therapy. The replacement of a systemic corticosteroid with a topical corticosteroid can be accompanied by signs of adrenal insufficiency. In addition, some patients may experience symptoms of corticosteroid withdrawal, e.g., joint and/or muscular pain, lassitude, and depression. Patients previously treated for prolonged periods with systemic corticosteroids and transferred to topical corticosteroids should be carefully monitored for acute adrenal insufficiency in response to stress. In those patients who have asthma or other clinical conditions requiring long-term systemic corticosteroid treatment, rapid decreases in systemic corticosteroid dosages may cause a severe exacerbation of their symptoms.

5.5 Effect on Growth Corticosteroids, including Triamcinolone Acetonide Nasal Spray, may cause a reduction in growth velocity when administered to pediatric patients. Monitor the growth routinely of pediatric patients receiving Triamcinolone Acetonide Nasal Spray. To minimize the systemic effects of intranasal corticosteroids, including Triamcinolone Acetonide Nasal Spray, titrate each patient's dose to the lowest dosage that effectively controls his/her symptoms.

Adverse Reactions

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.

In placebo-controlled, double-blind, and open-label clinical studies, 1483 adults and children 12 years and older received treatment with Triamcinolone Acetonide Nasal Spray. These patients were treated for an average duration of 51 days. In the controlled trials (2–5 weeks duration) from which the following adverse reaction data are derived, 1394 patients were treated with Triamcinolone Acetonide Nasal Spray for an average of 19 days. In a long-term, open-label study, 172 patients received treatment for an average duration of 286 days. Adverse reactions from 12 studies in adults and adolescent patients 12 to 17 years of age receiving Triamcinolone Acetonide Nasal Spray 27.5 mcg to 440 mcg once daily are summarized in Table 1.

In clinical trials, nasal septum perforation was reported in one adult patient who received Triamcinolone Acetonide Nasal Spray.

This image is provided by the National Library of Medicine.

A total of 602 children 6 to 12 years of age were studied in 3 double-blind, placebo-controlled clinical trials. Of these, 172 received 110 mcg/day and 207 received 220 mcg/day of Triamcinolone Acetonide Nasal Spray for two, six, or twelve weeks. The longest average durations of treatment for patients receiving 110 mcg/day and 220 mcg/day were 76 days and 80 days, respectively. One percent of patients treated with Triamcinolone Acetonide were discontinued due to adverse experiences. No patient receiving 110 mcg/day and one patient receiving 220mcg/day discontinued due to a serious adverse event. A similar adverse reaction profile was observed in pediatric patients 6–12 years of age as compared to adolescents and adults with the exception of epistaxis which occurred in less than 2% of the children studied. Adverse reactions from 2 studies in children 4 to 12 years of age receiving Triamcinolone Acetonide Nasal Spray 110 mcg once daily are summarized in Table 2.

This image is provided by the National Library of Medicine.

A total of 474 children 2 to 5 years of age were studied in a 4-week double-blind, placebo-controlled clinical trial. Of these, 236 received 110 mcg/day of Triamcinolone Acetonide Nasal Spray for a mean duration of 28 days. No patient discontinued due to a serious adverse event. Adverse reactions from the single placebo-controlled study in children 2 to 5 years of age receiving Triamcinolone Acetonide Nasal Spray 110 mcg once daily are summarized in Table 3.

This image is provided by the National Library of Medicine.

In the event of accidental overdose, an increased potential for these adverse experiences may be expected, but acute systemic adverse experiences are unlikely.

Postmarketing Experience

In addition to the adverse drug reactions reported during clinical studies and listed above, the following adverse reactions have been identified during post-approval use of Triamcinolone Acetonide Nasal Spray. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Reactions that have been reported during post-marketing experience include: nasal discomfort and congestion, sneezing, alterations of taste and smell, nausea, insomnia, dizziness, fatigue, dyspnea, decreased blood cortisol, cataract, glaucoma, increased ocular pressure, pruritus, rash, and hypersensitivity.

Drug Interactions

There is limited information regarding Triamcinolone (nasal) Drug Interactions in the drug label.

Use in Specific Populations

Pregnancy

Pregnancy Category (FDA): C There are no adequate and well-controlled studies of Triamcinolone Acetonide Nasal Spray in pregnant women. Triamcinolone acetonide was teratogenic in rats, rabbits, and monkeys. Triamcinolone Acetonide Nasal Spray, like other corticosteroids, should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Since their introduction, experience with oral corticosteroids in pharmacologic as opposed to physiologic doses suggests that rodents are more prone to teratogenic effects from corticosteroids than humans. In addition, because there is a natural increase in glucocorticoid production during pregnancy, most women will require a lower exogenous corticosteroid dose and many will not need corticosteroid treatment during pregnancy.

In reproduction studies in rats and rabbits, triamcinolone acetonide administered by inhalation produced cleft palate and/or internal hydrocephaly and axial skeletal defects at exposures less than and 2 times, respectively, the maximum recommended daily intranasal dose in adults on a mcg/m2 basis. In a monkey reproduction study, triamcinolone acetonide administered by inhalation produced cranial malformations at an exposure approximately 37 times the maximum recommended daily intranasal dose in adults on a mcg/m2 basis.
Pregnancy Category (AUS): There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Triamcinolone (nasal) in women who are pregnant.

Labor and Delivery

There is no FDA guidance on use of Triamcinolone (nasal) during labor and delivery.

Nursing Mothers

It is not known whether triamcinolone acetonide is excreted in human milk. Because other corticosteroids are excreted in human milk, caution should be exercised when Triamcinolone Acetonide Nasal Spray is administered to nursing women.

Pediatric Use

The safety and effectiveness of Triamcinolone Acetonide Nasal Spray has been evaluated in 464 children 2 to 5 years of age, 518 children 6 to 12 years of age, and 176 adolescents 12 to 17 years of age. The safety and effectiveness of Triamcinolone Acetonide Nasal Spray in children below 2 years of age have not been established.

Controlled clinical studies have shown that intranasal corticosteroids may cause a reduction in growth velocity in pediatric patients. This effect has 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 reduction in growth velocity associated with intranasal corticosteroids, including the impact on final adult height are unknown. The potential for "catch-up" growth following discontinuation of treatment with intranasal corticosteroids has not been adequately studied. The growth of pediatric patients receiving intranasal corticosteroids, including Triamcinolone Acetonide Nasal Spray, should be monitored routinely (e.g., via stadiometry). The potential growth effects of treatment should be weighed against the clinical benefits obtained and the risks/benefits of treatment alternatives. To minimize the systemic effects of intranasal corticosteroids, including Triamcinolone Acetonide Nasal Spray, each patient's dose should be titrated to the lowest dosage that effectively controls his/her symptoms.

The effect of Triamcinolone Acetonide Nasal Spray on growth velocity in children was assessed in a 12 month randomized, placebo controlled study conducted in 299 prepubescent children age 3 to 9 years (173 males, 126 females) with perennial allergic rhinitis. Treatment groups were Triamcinolone Acetonide Nasal Spray 110 mcg once daily and placebo. Growth velocity was estimated for each patient using the slope of the linear regression of height over time using observed data in the intent to treat population who had at least 3 height measurements after randomization. Growth velocities were significantly lower in the Triamcinolone Acetonide Nasal Spray group compared to placebo, with a mean growth velocity of 6.09 cm/year in the placebo group and 5.65 cm/year in the Triamcinolone Acetonide Nasal Spray treated group (difference from placebo -0.45 cm/year; 95% CI: -0.78, -0.11).

Geriatic Use

Clinical studies of Triamcinolone Acetonide did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

Gender

There is no FDA guidance on the use of Triamcinolone (nasal) with respect to specific gender populations.

Race

There is no FDA guidance on the use of Triamcinolone (nasal) with respect to specific racial populations.

Renal Impairment

There is no FDA guidance on the use of Triamcinolone (nasal) in patients with renal impairment.

Hepatic Impairment

There is no FDA guidance on the use of Triamcinolone (nasal) in patients with hepatic impairment.

Females of Reproductive Potential and Males

There is no FDA guidance on the use of Triamcinolone (nasal) in women of reproductive potentials and males.

Immunocompromised Patients

There is no FDA guidance one the use of Triamcinolone (nasal) in patients who are immunocompromised.

Administration and Monitoring

Administration

There is limited information regarding Triamcinolone (nasal) Administration in the drug label.

Monitoring

There is limited information regarding Triamcinolone (nasal) Monitoring in the drug label.

IV Compatibility

There is limited information regarding the compatibility of Triamcinolone (nasal) and IV administrations.

Overdosage

Chronic overdosage may result in signs/symptoms of hypercorticism. There are no data on the effects of acute or chronic overdosage with Triamcinolone Acetonide Nasal Spray. Because of low systemic bioavailability and an absence of acute drug-related systemic findings in clinical studies overdose is unlikely to require any therapy other than observation.

Acute overdosing with the intranasal dosage form is unlikely in view of the total amount of active ingredient present and low bioavailability of triamcinolone acetonide. In the event that the entire contents of the bottle were administered all at once, via either oral or nasal application, clinically significant systemic adverse events would most likely not result.

Pharmacology

Triamcinolone (nasal)
Systematic (IUPAC) name
(11β,16α)-9-Fluoro-11,16,17,21-tetrahydroxypregna-1,4-diene-3,20-dione
Identifiers
CAS number	124-94-7
ATC code	A01AC01 C05AA12 (WHO), D07AB09 (WHO), H02AB08 (WHO), R01AD11 (WHO), R03BA06 (WHO), S01BA05 (WHO)
PubChem	31307
DrugBank	DB00620
Chemical data
Formula	Template:OrganicBox atomTemplate:OrganicBox atomTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBox atomTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBox atomTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBoxTemplate:OrganicBox
Mol. mass	394.434 g/mol
SMILES	eMolecules & PubChem
Synonyms	Click show to see (8S,9R,10S,11S,13S,14S,16R,17S)-9-fluoro-11,16,17-trihydroxy-17-(2-hydroxyacetyl)-10,13-dimethyl-6,7,8,9,10,11,12,13,14,15,16,17-dodecahydro-3H-cyclopenta[a]phenanthren-3-one; (1R,2S,10S,11S,13R,14S,15S,17S)-1-fluoro-13,14,17-trihydroxy-14-(2-hydroxyacetyl)-2,15-dimethyltetracyclo[8.7.0.02,7.011,15]heptadeca-3,6-dien-5-one
Pharmacokinetic data
Bioavailability	?
Protein binding	68%
Metabolism	Hepatic
Half life	88 minutes
Excretion	Fecal and renal
Therapeutic considerations
Pregnancy cat.	A(AU) C(US)
Legal status	POM(UK) [[Prescription drug|Template:Unicode-only]](US)
Routes	Oral, topical, IM, intra-articular, intrasynovial

Mechanism of Action

Triamcinolone acetonide is a synthetic fluorinated corticosteroid with approximately 8 times the potency of prednisone in animal models of inflammation.

Although the precise mechanism of corticosteroid antiallergic action is unknown, corticosteroids have been shown to have a wide range of actions on multiple cell types (e.g., mast cells, eosinophils, neutrophils, macrophages, lymphocytes) and mediators (e.g., histamine, eicosanoids, leukotrienes, cytokines) involved in inflammation.

Structure

Triamcinolone acetonide, USP, the active ingredient in Triamcinolone Acetonide Nasal Spray, is a corticosteroid with a molecular weight of 434.51 and with the chemical designation 9-Fluoro-11β,16α,17,21-tetrahydroxypregna-1,4-diene-3,20-dione cyclic 16,17-acetal with acetone (C24H31FO6).

This image is provided by the National Library of Medicine.

Triamcinolone Acetonide Nasal Spray is a thixotropic, water-based metered-dose pump spray formulation unit containing a microcrystalline suspension of triamcinolone acetonide in an aqueous medium. Microcrystalline cellulose, carboxymethylcellulose sodium, polysorbate 80, dextrose, benzalkonium chloride, and edetate disodium are contained in this aqueous medium; hydrochloric acid or sodium hydroxide may be added to adjust the pH to a target of 5.0 within a range of 4.5 and 6.0.

Pharmacodynamics

In order to determine if systemic absorption plays a role in the effect of Triamcinolone Acetonide Nasal Spray on allergic rhinitis symptoms, a two week double-blind, placebo-controlled clinical study was conducted comparing Triamcinolone Acetonide, orally ingested triamcinolone acetonide, and placebo in 297 adult patients with seasonal allergic rhinitis. The study demonstrated that the therapeutic efficacy of Triamcinolone Acetonide Nasal Spray can be attributed to the topical effects of triamcinolone acetonide.

Adrenal Function: In order to evaluate the effects of systemic absorption on the Hypothalamic-Pituitary-Adrenal (HPA) axis, 4 clinical studies, one each in adults and in children 6–12 years of age, 2–5 years of age, and 2–11 years of age, were conducted.

The adult clinical study compared 220 mcg or 440 mcg Triamcinolone Acetonide per day, or 10 mg prednisone per day with placebo for 42 days. Adrenal response to a six-hour 250 mcg cosyntropin stimulation test showed that Triamcinolone Acetonide administered at doses of 220 mcg and 440 mcg had no statistically significant effect on HPA activity versus placebo. Conversely, oral prednisone at 10 mg/day significantly reduced the response to ACTH.

A study evaluating plasma cortisol response thirty and sixty minutes after 250 mcg cosyntropin stimulation in 80 pediatric patients 6 to 12 years of age who received 220 mcg or 440 mcg (twice the maximum recommended daily dose) daily for six weeks was conducted. No abnormal response to cosyntropin infusion (peak serum cortisol <18 mcg/dL) was observed in any pediatric patient after six weeks of dosing with Triamcinolone Acetonide at 440 mcg per day.

In pediatric patients 2 to 5 years of age (n = 61) receiving Triamcinolone Acetonide Nasal Spray 110 mcg per day intranasally, HPA axis function was assessed by cosyntropin stimulation test; however, the results were inconclusive.

An effect of Triamcinolone Acetonide Nasal Spray on adrenal function in children 2 to 5 years of age cannot be ruled out.

In a 6-week trial in 140 children 2 to 11 years of age with allergic rhinitis, a daily dose of 110 or 220 mcg of Triamcinolone Acetonide Nasal Spray was compared to placebo nasal spray. A subset of 24 children 6 to 11 years of age received a higher dose of 220 mcg of Triamcinolone Acetonide Nasal Spray. A positive control was not included in this trial. Adrenal function was assessed by measurement of 24 hour serum cortisol levels before and after the treatment. The difference from placebo in the change from baseline in LS mean serum cortisol AUC (0–24 hr) at the end of week 6 for the Triamcinolone Acetonide Nasal Spray treatment groups (110 mcg and 220 mcg) was -4.2 mcg∙hour/dL (95% CI: -14.7, 6.4).

Pharmacokinetics

Based upon intravenous dosing of triamcinolone acetonide phosphate ester in adults, the half-life of triamcinolone acetonide was reported to be 88 minutes. The volume of distribution (Vd) reported was 99.5 L (SD ± 27.5) and clearance was 45.2 L/hour (SD ± 9.1) for triamcinolone acetonide. The plasma half-life of corticosteroids does not correlate well with the biologic half-life.

Pharmacokinetic characterization of the Triamcinolone Acetonide Nasal Spray formulation was determined in both normal adult subjects and patients with allergic rhinitis. Single dose intranasal administration of 220 mcg of Triamcinolone Acetonide Nasal Spray in normal adult subjects and patients demonstrated minimal absorption of triamcinolone acetonide. The mean peak plasma concentration was approximately 0.5 ng/mL (range: 0.1 to 1.0 ng/mL) and occurred at 1.5 hours post dose. The mean plasma drug concentration was less than 0.06 ng/mL at 12 hours, and below the assay detection limit (the minimum LOQ of the assay was 0.025 ng/ml) at 24 hours. The average terminal half-life was 3.1 hours. The range of mean AUC0–∞ values was 1.4 ng∙hr/mL to 4.7 ng∙hr/mL between doses of 110 mcg to 440 mcg in both patients and healthy volunteers. Dose proportionality was demonstrated in both normal adult subjects and in allergic rhinitis patients following single intranasal doses of 110 mcg or 220 mcg Triamcinolone Acetonide Nasal Spray. The Cmax and AUC0–∞ of the 440 mcg dose increased less than proportionally when compared to 110 and 220 mcg doses.

Following multiple dose administration of Triamcinolone Acetonide 440 mcg once daily in pediatric patients 6 to 12 years of age, plasma drug concentrations, AUC0–∞, Cmax and Tmax were similar to those values observed in adult patients receiving the same dose. Intranasal administration of Triamcinolone Acetonide 110 mcg once daily in pediatric patients 2 to 5 years of age exhibited similar systemic exposure to that achieved in adult patients 20 to 49 years of age with intranasal administration of Triamcinolone Acetonide at a dose of 220 mcg once daily. Based on the population pharmacokinetic modeling, the apparent clearance and volume of distribution following intranasal administration of Triamcinolone Acetonide in pediatric patients 2 to 5 years of age were found to be approximately half of that in adults.

In animal studies using rats and dogs, three metabolites of triamcinolone acetonide have been identified. They are 6β-hydroxytriamcinolone acetonide, 21-carboxytriamcinolone acetonide and 21-carboxy-6β-hydroxytriamcinolone acetonide. All three metabolites are expected to be substantially less active than the parent compound due to (a) the dependence of anti-inflammatory activity on the presence of a 21-hydroxyl group, (b) the decreased activity observed upon 6-hydroxylation, and (c) the markedly increased water solubility favoring rapid elimination. There appeared to be some quantitative differences in the metabolites among species. No differences were detected in metabolic pattern as a function of route of administration.

Nonclinical Toxicology

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility In a two-year study in rats, triamcinolone acetonide caused no treatment-related carcinogenicity at oral doses up to 1.0 mcg/kg (less than the maximum recommended daily intranasal dose in adults and children on a mcg/m2 basis, respectively). In a two-year study in mice, triamcinolone acetonide caused no treatment-related carcinogenicity at oral doses up to 3.0 mcg/kg (less than the maximum recommended daily intranasal dose in adults and children on a mcg/m2 basis, respectively).

No evidence of mutagenicity was detected from in vitro tests (a reverse mutation test in Salmonella bacteria and a forward mutation test in Chinese hamster ovary cells) conducted with triamcinolone acetonide.

In male and female rats, triamcinolone acetonide caused no change in pregnancy rate at oral doses up to 15.0 mcg/kg (less than the maximum recommended daily intranasal dose in adults on a mcg/m2 basis). Triamcinolone acetonide caused increased fetal resorptions and stillbirths and decreases in pup weight and survival at doses of 5.0 mcg/kg and above (less than the maximum recommended daily intranasal dose in adults on a mcg/m2 basis). At 1.0 mcg/kg (less than the maximum recommended daily intranasal dose in adults on a mcg/m2 basis), it did not induce the above mentioned effects.

13.2 Animal Toxicology and/or Pharmacology Triamcinolone acetonide was teratogenic in rats, rabbits, and monkeys. In rats, triamcinolone acetonide was teratogenic at an inhalation dose of 20 mcg/kg and above (approximately 7/10 of the maximum recommended daily intranasal dose in adults on a mcg/m2 basis). In rabbits, triamcinolone acetonide was teratogenic at inhalation doses of 20 mcg/kg and above (approximately 2 times the maximum recommended daily intranasal dose in adults on a mcg/m2 basis). In monkeys, triamcinolone acetonide was teratogenic at an inhalation dose of 500 mcg/kg (approximately 37 times the maximum recommended daily intranasal dose in adults on a mcg/m2 basis). Dose-related teratogenic effects in rats and rabbits included cleft palate and/or internal hydrocephaly and axial skeletal defects, whereas the effects observed in the monkey were cranial malformations.

Hypoadrenalism may occur in infants born of mothers receiving corticosteroids during pregnancy. Such infants should be carefully observed.

Clinical Studies

The safety and efficacy of Triamcinolone Acetonide Nasal Spray have been evaluated in 10 double-blind, placebo-controlled clinical studies of two- to four-weeks duration in adults and children 12 years and older with seasonal or perennial allergic rhinitis. The number of patients treated with Triamcinolone Acetonide Nasal Spray in these studies was 1266; of these patients, 675 were males and 591 were females.

Overall, the results of these clinical studies in adults and children 12 years and older demonstrated that Triamcinolone Acetonide Nasal Spray 220 mcg once daily (2 sprays in each nostril), when compared to placebo, provides statistically significant relief of nasal symptoms of seasonal or perennial allergic rhinitis including sneezing, stuffiness, discharge, and itching.

The safety and efficacy of Triamcinolone Acetonide Nasal Spray, at doses of 110 mcg or 220 mcg once daily, have also been adequately studied in two double-blind, placebo-controlled studies of two- and twelve-weeks duration in children ages 6 through 12 years with seasonal and perennial allergic rhinitis. These studies included 341 males and 177 females. Triamcinolone Acetonide administered at either dose resulted in statistically significant reductions in the severity of nasal symptoms of allergic rhinitis.

The safety and efficacy of Triamcinolone Acetonide Nasal Spray in children 2 to 5 years of age with perennial allergic rhinitis with or without seasonal allergic rhinitis was studied in a single 4 week double blind, placebo controlled clinical study with a 24 week open label extension conducted in the United States. The study included 464 patients (266 males and 198 females) 2 to 5 years of age who received at least one dose of study medication (233 placebo, 231 Triamcinolone Acetonide 110 mcg once daily). Efficacy was determined over a four-week double-blind, placebo-controlled treatment period and was based on patient's parent or guardian recording of four nasal symptoms (total nasal symptom score, TNSS), congestion, itching, rhinorrhea, and sneezing on a 0–3 categorical severity scale (0=absent, 1=mild, 2=moderate, and 3=severe) once daily. Reflective scoring (rTNSS) required recording symptom severity over the previous 24 hours; the instantaneous scoring (iTNSS) required recording symptom severity at the time just prior to dosing. Baseline symptom severity was comparable between Triamcinolone Acetonide and placebo respectively, for iTNSS (7.52, 7.61) and rTNSS (7.96, 7.87). While the 24-hour iTNSS over the 4-week double-blind period was numerically improved with Triamcinolone Acetonide (-2.28) vs. placebo (-1.92), the difference was not statistically significant (difference from placebo -0.36; 95% CI [-0.77, 0.06]; p value = 0.095). For the 24-hour rTNSS over the 4 week double-blind treatment period, Triamcinolone Acetonide 110 mcg once daily provided statistically significantly greater improvement from baseline (-2.31) versus placebo (-1.87) (difference from placebo -0.44; 95% CI [-0.84, -0.04]; p value = 0.033).

How Supplied

Triamcinolone Acetonide Nasal Spray, 55 mcg per spray, is supplied in a white high-density polyethylene container with a metered-dose pump unit, white nasal adapter, and patient instructions (NDC 0955-1710-16).

The contents of one 16.5 gram bottle provide 120 actuations. After 120 actuations, the amount of triamcinolone acetonide delivered per actuation may not be consistent and the unit should be discarded. Each actuation delivers 55 mcg triamcinolone acetonide from the nasal actuator after an initial priming of 5 sprays.

In the Patient Package Information, patients are provided with a check-off form to track usage.

Keep out of reach of children.

Storage

Store at Controlled Room Temperature, 20 to 25°C (68 to 77°F)

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Patient Counseling Information

17.1 Local Nasal Effects

Patients should be informed that treatment with Triamcinolone Acetonide Nasal Spray may lead to adverse reactions, which include epistaxis and nasal ulceration. Candida infection may also occur with treatment with Triamcinolone Acetonide Nasal Spray. In addition, nasal corticosteroids are associated with nasal septal perforation and impaired wound healing. Patients who have experienced recent nasal ulcers, nasal surgery, or nasal trauma should not use Triamcinolone Acetonide Nasal Spray until healing has occurred.

17.2 Cataracts and Glaucoma

Patients should be informed that glaucoma and cataracts are associated with nasal and inhaled corticosteroid use. Patients should inform his/her heath care provider if a change in vision is noted while using Triamcinolone Acetonide Nasal Spray.

17.3 Immunosuppression

Patients who are on immunosuppressant doses of corticosteroids should be warned to avoid exposure to chickenpox or measles and, if exposed, to consult their physician without delay. Patients should be informed of potential worsening of existing tuberculosis, fungal, bacterial, viral or parasitic infections, or ocular herpes simplex.

17.4 Effect on Growth

Parents should be advised that Triamcinolone Acetonide Nasal Spray may slow growth in children. A child taking Triamcinolone Acetonide Nasal Spray should have his/her growth checked regularly.

17.5 Use Daily for Best Effect

Patients should use Triamcinolone Acetonide Nasal Spray on a regular once-daily basis for optimal effect. It is also important to shake the bottle well before each use. Do not blow your nose for 15 minutes after using the spray. Triamcinolone Acetonide Nasal Spray, like other corticosteroids, does not have an immediate effect on rhinitis symptoms. Although improvement in some patient symptoms may be seen within the first day of treatment, maximum benefit may not be reached for up to one week. The patient should not increase the prescribed dosage but should contact the physician if symptoms do not improve or if the condition worsens.

17.6 Keep Spray Out of Eyes

Patients should be informed to avoid spraying Triamcinolone Acetonide Nasal Spray in their eyes.

IMPORTANT: Please read these instructions carefully before using your Triamcinolone Acetonide Nasal Spray

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Precautions with Alcohol

Alcohol-Triamcinolone (nasal) interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

Brand Names

There is limited information regarding Triamcinolone (nasal) Brand Names in the drug label.

Look-Alike Drug Names

• There is limited information regarding Look-Alike Drug Names.

Drug Shortage Status

Price

References

The contents of this FDA label are provided by the National Library of Medicine.