Triamcinolone: new and old indications

Role of steroid injection for skin thickness and edema in rhinoplasty patients

OBJECTIVES

The aim of this study was to observe the effect of the triamcinolone acetonide injections in thick skinned patients with ultrasonographic measurements and to compare these results with the postoperative nasal skin thickness of patients that were not injected with steroids.

METHODS

A prospective study was planned with 42 thick nasal skinned rhinoplasty candidates in our clinic. Skin thickness of specific points along nose was measured and documented. On the 10th day after surgery, triamcinolone acetonide injections were performed into the supratip region of 21 patients in the study group. No injections were made for the control group. Nasal ultrasonographic measurements were repeated 40 days after the surgery for all 42 patients by the same radiologist and results were evaluated.

RESULTS

Seventeen women (40.5%) and 25 men (59.5%) were included in the study. Patients' ages ranged from 18 to 53 with an average age of 27.9. In study group, all injections sites showed thinning on the 40th day after surgery. These findings were statistically significant at B (rhinion), D (middle of supratip), and G (middle of the tip). In the control group, all injection sites except A (nasion) displayed thickening on the 40th day after surgery. These findings were statistically significant at B (rhinion), D (middle of supratip), H (left side of the tip), and J (left alar region).

CONCLUSION

Triamcinolone acetonide injections are effective in the prevention of edema and provide thinning of the post-rhinoplasty skin envelope.

Structural Analysis of the Glucocorticoid Receptor Ligand-Binding Domain in Complex with Triamcinolone Acetonide and a Fragment of the Atypical Coregulator, Small Heterodimer Partner

The synthetic glucocorticoids (GCs) dexamethasone, mometasone furoate, and triamcinolone acetonide are pharmaceutical mainstays to treat chronic inflammatory diseases. These drugs bind to the glucocorticoid receptor (GR), a ligand-activated transcription factor and member of the nuclear receptor superfamily. The GR is widely recognized as a therapeutic target for its ability to counter proinflammatory signaling. Despite the popularity of GCs in the clinic, long-term use leads to numerous side effects, driving the need for new and improved drugs with less off-target pharmacology. X-ray crystal structures have played an important role in the drug-design process, permitting the characterization of robust structure-function relationships. However, steroid receptor ligand-binding domains (LBDs) are inherently unstable, and their crystallization requires extensive mutagenesis to enhance expression and crystallization. Here, we use an ancestral variant of GR as a tool to generate a high-resolution crystal structure of GR in complex with the potent glucocorticoid triamcinolone acetonide (TA) and a fragment of the small heterodimer partner (SHP). Using structural analysis, molecular dynamics, and biochemistry, we show that TA increases intramolecular contacts within the LBD to drive affinity and enhance stability of the receptor-ligand complex. These data support the emerging theme that ligand-induced receptor conformational dynamics at the mouth of the pocket play a major role in steroid receptor activation. This work also represents the first GR structure in complex with SHP, which has been suggested to play a role in modulating hepatic GR function.

Hypothalamic-pituitary-adrenal axis function following intravitreal triamcinolone acetonide injection

To evaluate the pituitary-adrenal axis function by means of the adrenocorticotropic hormone (ACTH) stimulation test following a single intravitreal injection of triamcinolone acetonide (IVTA). Prospective comparative clinical interventional study. Twenty-eight patients (28 eyes) received a single IVTA (4 mg in 0.1 ml) for macular edema. The basal cortisol level and the response to 1 μg adrenocorticotropic hormone stimulation were determined on the morning before IVTA injection and at 1 day and 1, 2, and 4 weeks after IVTA injection. Results were compared with those obtained from a control group of 50 healthy subjects. All patients in the study had normal basal cortisol and normal response to ACTH challenge before receiving IVTA. 1 day following IVTA, basal cortisol was suppressed in one patient in the study group. Fasting serum cortisol levels at 1, 2, and 4 weeks after IVTA injection were normal in all patients in the study group. 1 day following IVTA, the peak response to ACTH at 30 min was blunted in four patients (14.3 % of the study group, p = 0.05) and the cortisol response at 60 min was suppressed (p = 0.009). 1 week following IVTA, the response to ACTH challenge was blunted in only one patient. A single IVTA injection may be associated with impaired hypothalamic-pituitary-adrenal function in some patients during the first 24 h following IVTA.

Recent patents and emerging therapeutics in the treatment of allergic conjunctivitis

Ocular allergy is an inflammatory response of the conjunctival mucosa that also affects the cornea and eyelids. Allergic conjunctivitis includes seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC) and giant papillary conjunctivitis (GPC). In general, allergic conditions involve mast cell degranulation that leads to release of inflammatory mediators and activation of enzymatic cascades generating pro-inflammatory mediators. In chronic ocular inflammatory disorders associated with mast cell activation such as VKC and AKC constant inflammatory response is observed due to predominance of inflammatory mediators such as eosinophils and Th2-generated cytokines. Antihistamines, mast-cell stabilizers, nonsteroidal anti-inflammatory agents, corticosteroids and immunomodulatory agents are commonly indicated for the treatment of acute and chronic allergic conjunctivitis. In recent years newer drug molecules have been introduced in the treatment of allergic conjunctivitis. This article reviews recent patents and emerging therapeutics in the treatment of allergic conjunctivitis.

Pharmacotherapeutic efficacy of preservative-free intravitreal triamcinolone acetonide

Preservative-free formulations of triamcinolone acetonide have recently been introduced to the market over concerns of local toxicity of the vehicle and preservatives, including benzyl alcohol in the original formulation, which was not designed for intraocular use. The pharmacokinetics and pharmacodynamics of intravitreal triamcinolone (IVTA) are discussed. The therapeutic effects of IVTA include improvement of visual acuity and reduction of macular edema. However, ongoing treatment is usually required to maintain its effects. The efficacy of IVTA for both FDA-approved and 'off-labeled' indications is reviewed. Elevation of intraocular pressure and cataract formation are the two major side effects of IVTA; these are manageable but require close long-term follow-up. More studies are required to determine the optimal dosage and treatment frequency in different posterior segment disease.

Triamcinolone acetonide: a new management of noncompliance in nephrotic children

Noncompliance is frequent in children and adolescents with nephrotic syndrome. Once suspected, noncompliance is difficult to confirm and often impossible to avoid. The standard oral glucocorticoid treatment for children has been shown to be efficient and safe. However, a small number of children/parents are noncompliant to the steroid treatment, resulting in multiple relapses. For these patients the use of steroids with prolonged half-life such as triamcinolone acetonide (TA) can be helpful. We studied seven children (six boys, one girl; median age at diagnosis 8.6 years, range 1.8-10.7) receiving conventional steroid treatment for a median of 30 months (8-74) before starting intramuscular (IM) TA treatment. The standard prednisone treatment was replaced by 1 monthly IM injection of TA (1 mg/kg per day oral prednisone replaced by 1 mg/kg per month IM TA). The treatment was tapered off by a reduction of 10-20% of the initial dose per month over 6-8 months. After a mean observation period of 14 months (3-36) the results were evaluated in terms of number of relapses and treatment tolerance. Four children showed a clear decrease in number of relapses (1.8 to 0 per year); in the other three the number of relapses remained stable. Tolerance was excellent (no cataract, no arterial hypertension), and the cushingoid syndrome did not exceed the level experienced under conventional oral steroid therapy. However, growth velocity decreased during the TA treatment and returned to normal after discontinuation of TA. These preliminary results demonstrate that TA may be used in patients of suspected noncompliance in steroid-sensitive patients who respond with a complete remission during TA treatment over the observation period. Patients who do not benefit from the TA can be classified as very probably steroid-dependent. TA seems to be a useful therapeutic strategy in those patients for whom noncompliance is strongly suspected.