What is the role of triamcinolone (a corticosteroid) injection in the treatment of psoriatic arthritis?

From the Guidelines

Triamcinolone injections can be considered as an adjunctive therapy in psoriatic arthritis, particularly for patients with limited joint involvement or as a bridge therapy while waiting for systemic medications to take effect, as recommended by the most recent EULAR guidelines 1. The typical approach involves injecting triamcinolone acetonide directly into affected joints at doses ranging from 5-40 mg depending on joint size.

• Larger joints like knees typically receive higher doses (20-40 mg)
• Smaller joints receive lower doses (5-10 mg) These injections are usually performed by rheumatologists or orthopedic specialists using sterile technique, sometimes with ultrasound guidance for precise placement. The effects of triamcinolone injections typically last 6-12 weeks, and injections can be repeated, though generally limited to 3-4 times per year per joint to minimize side effects. Triamcinolone works by suppressing inflammation in the joint, reducing pain, swelling, and improving function. Potential side effects include temporary pain at the injection site, skin atrophy, infection risk, and temporary blood sugar elevation in diabetic patients. It's essential to note that while joint injections provide localized relief, they don't address the underlying systemic nature of psoriatic arthritis, so most patients will still require oral or injectable disease-modifying medications for comprehensive management, as outlined in the EULAR recommendations 1. According to the latest guidelines, treatment should be aimed at reaching the target of remission or, alternatively, minimal/low disease activity, by regular monitoring and appropriate adjustment of therapy 1. In patients with polyarthritis, or those with monoarthritis/oligoarthritis and poor prognostic factors, a csDMARD should be initiated rapidly, with methotrexate preferred in those with clinically relevant skin involvement 1. Local injections of glucocorticoids, such as triamcinolone, may be considered as adjunctive therapy in psoriatic arthritis, as stated in the updated recommendations 1.

From the FDA Drug Label

Rheumatic disorders: As adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in acute gouty arthritis; acute rheumatic carditis; ankylosing spondylitis; psoriatic arthritis; rheumatoid arthritis, including juvenile rheumatoid arthritis (selected cases may require low-dose maintenance therapy)

Intra-Articular The intra-articular or soft tissue administration of triamcinolone acetonide injectable suspension is indicated as adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in acute gouty arthritis, acute and subacute bursitis, acute nonspecific tenosynovitis, epicondylitis, rheumatoid arthritis, synovitis of osteoarthritis.

Triamcinolone injection is indicated for the treatment of psoriatic arthritis as an adjunctive therapy for short-term administration to tide the patient over an acute episode or exacerbation.

• The intra-articular administration of triamcinolone acetonide injectable suspension is used for this purpose.
• The initial dose for intra-articular administration is 2.5 mg to 5 mg for smaller joints and 5 mg to 15 mg for larger joints, depending on the specific disease entity being treated 2.
• For adults, doses up to 10 mg for smaller areas and up to 40 mg for larger areas have usually been sufficient 2.

From the Research

Treatment Options for Psoriatic Arthritis

• Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used as initial treatment for PsA, but there is limited data on their efficacy 3, 4
• Synthetic disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, sulfasalazine, leflunomide, and ciclosporin are also used to treat PsA, with varying levels of evidence supporting their efficacy 5, 3, 4
• Biologic agents, including anti-tumor necrosis factor (anti-TNF) agents, have shown good evidence for efficacy in treating PsA 3, 6
• Local and systemic corticosteroids, including triamcinolone injections, may be used to treat PsA, but there is limited data on their efficacy in this specific context 3, 4

Efficacy of Triamcinolone Injections in PsA

• There is no direct evidence in the provided studies on the efficacy of triamcinolone injections in PsA
• However, the use of local and systemic corticosteroids, including triamcinolone, is mentioned as part of the treatment options for PsA 3, 4
• The efficacy of corticosteroids in treating PsA is not well established, and more research is needed to determine their effectiveness in this context 4

Current Treatment Guidelines for PsA

• Treatment guidelines for PsA have been developed by various organizations, including the American College of Rheumatology (ACR), the European League Against Rheumatism (EULAR), and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 7
• These guidelines recommend a treat-to-target approach, with the goal of achieving remission or low disease activity 6, 7
• The guidelines also emphasize the importance of individualizing treatment based on patient characteristics, disease severity, and response to therapy 7