Can Kenalog (Triamcinolone) 40 mg/ml suspension be mixed with Lidocaine for intra-articular injection?

From the Guidelines

Mixing Kenalog 40 mg/ml suspension with lidocaine for intra-articular injection is a common practice and is generally considered acceptable, as long as aseptic technique is used and the mixture is administered immediately after preparation. When performing this mixture, it is essential to use sterile technique to minimize the risk of septic arthritis, which, although low, can occur with intra-articular injections, as noted in a recent study with a risk of 0.035% 1. The typical mixture might include 1 mL of Kenalog 40 mg/mL with 1-3 mL of 1% or 2% lidocaine without epinephrine.

Key Considerations

• The lidocaine provides immediate pain relief while waiting for the steroid's anti-inflammatory effects to begin, which typically takes 24-48 hours.
• When mixing the medications, gently invert the syringe to mix rather than shaking vigorously, as shaking can cause foaming and potentially alter the steroid crystals.
• Be aware that some patients may experience a "steroid flare" - temporary increased pain for 24-48 hours after injection.
• Lidocaine is contraindicated in patients with known allergies to amide-type local anesthetics.
• The pH difference between the medications doesn't significantly impact efficacy in most clinical scenarios, though theoretically it could affect particle size of the steroid suspension.

Clinical Guidance

• Patients should be offered local anaesthetic, explaining the pros and cons, as it can reduce discomfort during the procedure and extend pain reduction effect, as suggested by the EULAR recommendations for intra-articular therapies 1.
• Topical anaesthetics such as eutectic mixture of local anaesthetic cream or ethyl chloride spray can also reduce pain from the needle.
• It is crucial to inform diabetic patients about the risk of transient increased glycaemia following IA glucocorticoid injection and advise them to monitor glucose levels, especially from the first to third day post-injection 1.

From the Research

Intra-Articular Injection of Kenalog (Triamcinolone) 40 mg/ml Suspension with Lidocaine

• The combination of Kenalog (Triamcinolone) and Lidocaine for intra-articular injection has been studied in various research papers 2, 3, 4.
• A study published in 2015 compared the effects of ultrasound-guided intra-articular ketorolac versus corticosteroid injection in osteoarthritis of the hip, where 50 patients received a mixture of 0.5% lidocaine and triamcinolone 2.
• Another study in 2011 investigated the accuracy of a modified anteriolateral portal for intra-articular injection of the knee, where 80 mg of triamcinolone acetonide were injected into the knee with a 2.0-in (5.1-cm) 21-gauge needle after hydrodissection of the synovial membrane with lidocaine 3.
• A 2022 study compared the clinical effectiveness of adding a single ultrasound-guided intra-articular hip injection of corticosteroid and local anaesthetic to advice and education in adults with hip osteoarthritis, where 66 participants received ultrasound-guided injection of 40 mg triamcinolone acetonide and 4 mL 1% lidocaine hydrochloride 4.
• The pharmacology of intra-articular triamcinolone has been explored in a 2014 article, which discusses the clinical actions of intra-articular injections of corticosteroids in the management of inflammatory joint diseases 5.

Key Findings

• The studies suggest that the combination of Kenalog (Triamcinolone) and Lidocaine can be used for intra-articular injection, but the effectiveness and safety of this combination may vary depending on the specific condition being treated and the individual patient 2, 3, 4.
• The 2022 study found that the addition of a single ultrasound-guided intra-articular hip injection of corticosteroid and local anaesthetic to advice and education resulted in greater mean improvement in hip pain intensity over six months compared to advice and education alone 4.
• The 2014 article highlights the importance of understanding the pharmacokinetics, pharmacodynamics, and clinical pharmacology of triamcinolone acetonide (TA) and triamcinolone hexacetonide (TH) in the management of inflammatory joint diseases 5.