What are the risks of using Nasacort (triamcinolone) in patients with glaucoma?

Risks of Using Nasacort (Triamcinolone) in Patients with Glaucoma

Nasacort (triamcinolone acetonide) nasal spray is generally safe for glaucoma patients as the nasal formulation has minimal risk of causing intraocular pressure elevation compared to other routes of corticosteroid administration.

Understanding the Risk Profile

Intranasal triamcinolone (Nasacort) has a significantly different risk profile for glaucoma patients compared to other forms of corticosteroids:

• Nasal vs. Other Routes: While corticosteroids in general can pose risks for glaucoma patients, the nasal administration route presents minimal systemic absorption compared to oral, injectable, or ophthalmic formulations.

• FDA Labeling: According to the FDA labeling information, Nasacort is primarily contraindicated in patients with hypersensitivity to the medication or its components, not specifically for glaucoma 1.

Mechanism of Risk

When considering corticosteroids and glaucoma:

1. Topical Ocular Steroids: These pose the highest risk as they directly contact ocular tissues

   • Can cause significant IOP elevation
   • May lead to steroid-induced glaucoma

2. Intravitreal Steroids: Studies show that intravitreal triamcinolone can cause:

   • IOP elevation in 62.3% of patients
   • Significant pressure rises (≥10 mmHg) in 29.9% of patients
   • More difficult IOP control in patients with pre-existing open-angle glaucoma 2

3. Nasal Steroids: Minimal systemic absorption with limited effect on intraocular pressure

   • Much lower risk profile than other administration routes

Special Considerations

Pre-existing Glaucoma

• Patients with open-angle glaucoma should be monitored more carefully as they may be more susceptible to steroid-induced IOP elevation
• In one study, 50% of open-angle glaucoma patients receiving intravitreal triamcinolone experienced IOP >30 mmHg 2

Monitoring Recommendations

For glaucoma patients using Nasacort:

• Baseline IOP measurement before starting therapy
• Follow-up IOP check within 4-8 weeks of starting treatment
• Regular monitoring during continued use

Evidence-Based Perspective

A key study addressing corticosteroid use in glaucoma patients concluded: "For all practical purposes, the package insert warning for drugs that may dilate the pupil can be ignored when considering them for glaucoma patients of any type. However, the chronic use of corticosteroids, especially as eye drops, can pose a real danger to patients with open-angle glaucoma" 3.

Clinical Decision Making

When prescribing Nasacort to glaucoma patients:

1. Benefit vs. Risk Assessment:

   • Weigh the therapeutic benefit for allergic rhinitis against the minimal risk of IOP elevation
   • Consider the severity of the patient's glaucoma and current IOP control

2. Alternative Options:

   • For patients with poorly controlled or advanced glaucoma, consider second-generation oral antihistamines as an alternative
   • The American Academy of Otolaryngology-Head and Neck Surgery recommends oral second-generation antihistamines for primary complaints of sneezing and itching 1

3. Patient Education:

   • Inform patients about potential symptoms of increased IOP (eye pain, headache, blurred vision)
   • Emphasize the importance of regular ophthalmology follow-ups

Conclusion

While all corticosteroids theoretically carry some risk for glaucoma patients, the intranasal formulation of triamcinolone (Nasacort) presents minimal risk when used as directed. The primary concern should be for patients using ophthalmic corticosteroid preparations or those receiving intravitreal injections, rather than those using nasal sprays.