Kenalog
Kenalog
Generic Name
Kenalog
Brand Names
for triamcinolone acetonide) is a potent synthetic glucocorticoid used for a variety of inflammatory, allergic, and autoimmune conditions. It is available in oral, topical, and injectable formulations and is favored for its high bioavailability and minimal mineralocorticoid activity.
Mechanism
- Glucocorticoid receptor (GR) agonist: Triamcinolone enters cells via passive diffusion, binds the intracellular GR, and translocates to the nucleus.
- Transrepression: Inhibits NF‑κB and AP‑1, reducing transcription of pro‑inflammatory cytokines (IL‑1, IL‑6, TNF‑α) and chemokines.
- Transactivation: Stimulates expression of anti‑inflammatory proteins such as annexin‑1 and lipocortin‑1.
- Immunomodulation: ↓ Lymphocyte proliferation, ↓ eosinophil recruitment, and ↓ mast cell degranulation.
- Reduced vascular permeability and inhibition of bradykinin/serotonin pathways diminish edema and pain.
Pharmacokinetics
| Parameter | Typical Value | Notes |
| Absorption | Oral 50‑70 % bioavailability; intramuscular (IM) 100 % | IM onset ~30 min; oral half‑life 3–4 h |
| Distribution | Extensive; protein binding ~85 % | Crosses placenta; breast‑milk minimal |
| Metabolism | Hepatic (CYP3A4, CYP1A2) → hydroxylated metabolites | No active metabolites |
| Elimination | Renal (≈40 %) and fecal (≈30 %) | Half‑life 3–4 h; accumulation with repeated dosing |
| Special Populations | Renal/hepatic impairment: dosage adjustments; pregnancy: category C |
Indications
- Ophthalmology: Allergic conjunctivitis, uveitis, posterior segment inflammation, post‑operative ocular inflammation.
- Dermatology: Psoriasis, eczema, dermatitis, cutaneous sarcoidosis, alopecia areata.
- Lung: Asthma exacerbations, allergic bronchopulmonary aspergillosis, chronic obstructive pulmonary disease (COPD) flare‑up.
- Joint & Soft Tissue: Rheumatoid arthritis (intra‑articular), osteoarthritis, gout, tendinopathies, bursitis.
- ENT: Allergic rhinitis, sinusitis, nasal polyposis; can be used intranasally.
- Systemic: Autoimmune diseases (e.g., systemic lupus erythematosus) when oral therapy is indicated.
Contraindications
- Contraindications: Active systemic fungal infections, untreated tuberculosis, systemic viral infections, hypersensitivity to triamcinolone or other corticosteroids.
- Warnings:
- Systemic exposure → adrenal insufficiency, Cushingoid changes, hypertension.
- Ocular forms → ocular hypertension, glaucoma, cataract progression, secondary infection.
- Topical use over large skin areas → systemic effects in children.
- Use cautiously in diabetes, hypertension, osteoporosis, osteoporosis‑prone patients.
Dosing
| Indication | Form | Typical Dose | Frequency | Notes |
| Intramuscular injection | Kenalog 10 mg/2 mL | 10–40 mg | Every 4–6 weeks | Monitor for local pain, muscle weakness |
| Topical cream/fabric | 0.1–0.5 % triamcinolone | 2 g once daily | 14–28 days | Avoid application >10 % body surface area |
| Ophthalmic | Kenalog 0.1% (drops) | 4×/day | 5–14 days | Use only under ophthalmologist supervision |
| Intranasal | 1‑2 mg/day | 2–3 mg/day | 5–21 days | Use 1–2 sprays; alternate nostrils |
| Oral | 0.5‑2 mg/kg | 20–60 mg | 1–2 days for flare | Not first‐line systemic therapy |
> Dosing tip: For intra‑articular injections, combine Kenalog with local anesthetic (e.g., lidocaine) to reduce post‑injection pain.
Adverse Effects
Common (≤10 %)
• Mood changes, insomnia, increased appetite, hyperglycemia
• Local pain at injection site, muscle aches, skin thinning (topical)
Serious (>10 %)
• Systemic Cushing syndrome, adrenal suppression (especially with chronic use)
• Osteoporosis, osteonecrosis (particularly with high‑dose IM)
• Hypertension, hyperlipidemia, peptic ulcer disease
• Opportunistic infections (e.g., candidiasis, tuberculosis)
• Serious ocular complications (elevated intra‑ocular pressure, cataract formation)
Monitoring
| Parameter | Frequency | Rationale |
| Serum glucose | Baseline, then 2–4 weeks | Prevent diabetic decompensation |
| Blood pressure | Baseline, then 2–4 weeks | Steroid‑induced hypertension |
| Serum potassium | Baseline, then as indicated | Rare hypokalemia with high‑dose steroids |
| Cortisol & ACTH | Before prolonged courses | Detect adrenal suppression |
| Bone density (DEXA) | Baseline for >6 months use | Osteoporosis prevention |
| Intra‑ocular pressure | Every 2 weeks in ocular use | Avoid glaucoma risk |
| Skin assessment | Baseline, then monthly (topicals) | Avoid atrophy, striae |
Clinical Pearls
- Kenalog vs. Hydrocortisone: Kenalog has ~5–10× greater potency and 13 % lower mineralocorticoid activity—ideal for conditions requiring strong anti‑inflammatory but minimal sodium retention.
- Kenalog in Ophthalmology: The drug’s viscosity allows sustained release from ocular implants; a single intravitreal Kenalog 0.4 mg can provide up to 6 months of anti‑inflammatory effect.
- Immunology: Despite high potency, Kenalog rarely induces systemic immunosuppression when used topically <10 % body area and for <4 weeks—this is why skin‑specific conditions often prefer it over systemic steroids.
- Drug Interactions: Concomitant CYP3A4 inhibitors (ketoconazole, erythromycin) may elevate triamcinolone levels; conversely, rifampin can reduce efficacy.
- Pediatric Use: Use lower doses than adult equivalents; monitor growth parameters, as chronic steroids can stunt growth velocity.
- Withdrawal Strategy: For chronic IM therapy, taper slowly over 4–6 weeks with 10‑mg reductions per dose; oral prednisolone can be used as a bridging agent.
- Pregnancy & Lactation: Kenalog is category C; use only if benefits outweigh risks, and avoid high‑dose systemic exposure. Low‑dose topical forms are generally considered safe if the area of contact is Final note: Kenalog remains a cornerstone in steroid therapy, offering high potency with a relatively favorable safety profile when used judiciously and monitored carefully.