What are the guidelines for using Kenalog (triamcinolone) IM (intramuscular) injections?

Kenalog IM (Triamcinolone Acetonide) Administration Guidelines

Direct Recommendation

Kenalog IM should be administered intramuscularly using a 22-25 gauge, 1-1½ inch needle at a 90-degree angle into the deltoid, anterolateral thigh, or ventrogluteal area, with dosing ranging from 40-80 mg depending on the clinical indication, and is FDA-approved for severe allergic, rheumatic, dermatologic, and endocrine conditions when oral therapy is not feasible. 1, 2

FDA-Approved Indications

Kenalog IM is indicated when oral corticosteroid therapy is not feasible for the following conditions 1:

• Allergic states: Severe or incapacitating allergic conditions including asthma, atopic dermatitis, contact dermatitis, drug hypersensitivity reactions, allergic rhinitis 1
• Rheumatic disorders: Acute gouty arthritis, acute rheumatic carditis, ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis (as adjunctive therapy for acute episodes) 1
• Dermatologic diseases: Bullous dermatitis herpetiformis, exfoliative erythroderma, mycosis fungoides, pemphigus, severe Stevens-Johnson syndrome 1
• Endocrine disorders: Primary or secondary adrenocortical insufficiency, congenital adrenal hyperplasia, hypercalcemia associated with cancer 1
• Respiratory diseases: Berylliosis, pulmonary tuberculosis (with appropriate antituberculous therapy), idiopathic eosinophilic pneumonias, symptomatic sarcoidosis 1

Proper Injection Technique

Site Selection and Needle Specifications

• Use a 22-25 gauge, 1-1½ inch needle for adult intramuscular injections 2
• Insert the needle at a 90-degree angle to ensure proper muscle penetration 2
• Preferred injection sites include: deltoid muscle (preferred for adults), anterolateral thigh, and ventrogluteal area 2
• For patients with increased subcutaneous tissue thickness, longer needles may be required to reach muscle mass 2

Site Rotation

Rotate injection sites to prevent tissue damage and ensure proper absorption 2. This is critical for patients receiving repeated injections to avoid local complications.

Dosing by Clinical Indication

Standard IM Dosing

• Kenalog-40: 40 mg/mL formulation available in 1 mL, 5 mL, and 10 mL vials 1
• Kenalog-80: 80 mg/mL formulation available in 1 mL and 5 mL vials 1

Specific Clinical Scenarios

• Acute crystal-induced arthritis (gout): 60 mg intramuscular for monoarticular or oligoarticular attacks 3
• Large joint injections: 20-40 mg per injection 3
• Alopecia areata: 5-10 mg/mL concentration injected into affected areas 3
• Resistant dermatologic lesions: 10-20 mg/mL concentration 3
• Pes anserine bursa: 20-40 mg total dose, using 0.05-0.1 mL per injection site 3
• Adrenal insufficiency in pediatric patients: 2-3 mg/kg (maximum 100 mg) over 3-5 minutes, followed by maintenance dosing 3

High-Dose Regimen for Severe Asthma

For highly select elderly patients with severe, chronic, steroid-dependent asthma, a single 360 mg intramuscular injection has demonstrated marked functional improvement with response durations ranging from 3 to 24 months 4. However, this high-dose approach requires careful patient selection and monitoring.

Critical Safety Considerations and Monitoring

Absolute Contraindications

• Active infections at injection sites (impetigo or herpes) 3
• Hypersensitivity to triamcinolone 3
• Extensive plaque psoriasis, pustular psoriasis, or erythrodermic psoriasis 3

Use With Caution

Exercise caution in patients with diabetes, heart failure, or severe hypertension 3, as corticosteroids can exacerbate these conditions.

Required Monitoring and Prophylaxis

• Consider Pneumocystis prophylaxis with trimethoprim-sulfamethoxazole if using ≥20 mg of corticosteroids for 4 weeks or longer 2
• Monitor bone health with dual-energy x-ray absorptiometry due to risk of osteoporosis, compression fractures, and avascular necrosis with prolonged use 2
• Monitor for hypertension, weight gain, growth delay in children, cataracts, diabetes, and dyslipidemia 2
• Ophthalmologic examinations every 3-6 months while receiving the medication 5, as lens opacities can develop

HPA Axis Suppression

The hypothalamic-pituitary-adrenal (HPA) axis function can be suppressed during treatment and up to 10 months after cessation of therapy 5. Patients who have received triamcinolone acetonide should be given supportive doses of corticosteroids during stressful situations such as major surgery 5.

Discontinuation Protocol

Avoid abrupt discontinuation of Kenalog; gradual tapering is necessary to prevent adrenal insufficiency 2. This is particularly important given the prolonged duration of action of intramuscular triamcinolone.

Common Adverse Effects

Local Reactions

Local reactions including skin atrophy, telangiectasia, pigmentary changes, striae, and folliculitis can occur 3. Facial applications require particular caution due to thinner skin and higher risk of steroid-induced atrophy 3. Intertriginous areas should be treated sparingly to minimize atrophy risk 3.

Systemic Side Effects

• Hypertension is the most common grade 3 toxicity (44% in one study), though only 9% required concomitant medication 6
• Proximal myopathy observed in 40% of patients 6
• Weight gain, menstrual disturbances, edema, and spontaneous ecchymoses 7
• Transient weakness and diabetes may occur during the first week of therapy 4

Unique Pharmacokinetic Properties

The enigma of triamcinolone acetonide's purported efficacy lies in its unique long-term effect on disease using seemingly low doses compared with other routes of administration 8. This may be attributed to:

• Differing binding mechanisms at the intramuscular site 8
• Low solubility in blood due to acetonide esters 8
• Slow rate of absorption from the injected site 8
• Low renal clearance rate 8

These properties explain why intramuscular triamcinolone maintains potent effects over a longer period compared with other corticosteroids 8.

Clinical Pearls for Specific Applications

• Intralesional treatment for inflammatory nodulocystic acne flattens most nodules within 48-72 hours 3
• For severe intrinsic asthma, 88.3% of patients showed excellent or good results with repeated intramuscular injections 7
• Patients with severe asthma showed marked functional improvement within 1 week of receiving injection, with peak expiratory flow rates rising between 25-93% 4