What is the appropriate dose of Kenalog (triamcinolone acetonide) for a 240‑pound (≈109 kg) adult male with severe allergic reaction and uvular edema?

Kenalog Dosing for Severe Allergic Reaction with Uvular Edema

For a 240-pound (109 kg) adult male with severe allergic reaction and swollen uvula, administer intramuscular epinephrine 0.3–0.5 mg (1:1000) immediately into the anterolateral thigh as first-line treatment, followed by triamcinolone acetonide (Kenalog) 60–80 mg IM as adjunctive therapy to prevent biphasic reactions. 1

Critical First-Line Treatment: Epinephrine

• Epinephrine is the only first-line treatment for anaphylaxis and must be given immediately before any other medication, including corticosteroids. 1
• The presentation of severe allergies with swollen uvula meets clinical criteria for anaphylaxis (acute onset with skin/mucous membrane involvement including swollen uvula). 2
• Administer epinephrine 0.3–0.5 mg IM (1:1000 solution) into the anterolateral thigh, which can be repeated every 5–15 minutes if symptoms persist. 2, 1
• Position the patient supine with legs elevated unless respiratory distress is present, in which case keep seated upright. 1

Kenalog (Triamcinolone Acetonide) Dosing

Standard Systemic Dose

• The FDA-approved initial systemic dose is 60 mg injected deeply into the gluteal muscle, with dosage typically adjusted within the range of 40–80 mg depending on patient response. 3
• For a 240-pound (109 kg) patient, 60–80 mg IM is appropriate based on the standard dosing range. 3
• Some patients may require doses as low as 20 mg or as high as 100 mg depending on disease severity and response. 3

Alternative Corticosteroid Dosing

• Methylprednisolone 1–2 mg/kg IV (approximately 109–218 mg for this patient, typically given as 40 mg IV every 6 hours) is an alternative to Kenalog. 1
• Hydrocortisone 200 mg IV as a single dose is another option. 1
• Corticosteroids serve only as adjunctive therapy to prevent biphasic reactions (which occur in 7–18% of cases) and provide no acute benefit in the immediate management of anaphylaxis. 2, 1

Complete Management Algorithm

Immediate Actions (First 5 Minutes)

• Epinephrine 0.3–0.5 mg IM into anterolateral thigh (repeat every 5–15 minutes if needed). 1
• Activate emergency medical services. 1
• Position patient appropriately (supine with legs elevated if hypotensive, seated if dyspneic). 1
• Administer supplemental oxygen and monitor vital signs continuously. 1

Adjunctive Medications (After Epinephrine)

• H1-antihistamine: Diphenhydramine 25–50 mg IV/IM (1–2 mg/kg). 1
• H2-antihistamine: Ranitidine 50 mg IV or famotidine 20 mg IV if ranitidine unavailable. 1
• Corticosteroid: Kenalog 60–80 mg IM or methylprednisolone 1–2 mg/kg IV every 6 hours. 1, 3

Fluid Resuscitation

• Establish IV access and administer 500–1000 mL crystalloid bolus (normal saline or lactated Ringer's) for adults with hypotension or incomplete response to epinephrine. 1

For Persistent Bronchospasm

• Albuterol nebulization 2.5–5 mg in 3 mL saline if bronchospasm is unresponsive to epinephrine. 1

Special Considerations for Beta-Blocker Patients

• If the patient is taking beta-blockers and remains hypotensive despite 2–3 doses of epinephrine and adequate fluid resuscitation, administer glucagon 1–5 mg IV over 5 minutes, followed by infusion of 5–15 µg/min. 2, 1
• Glucagon works through non-β-adrenergic pathways and can overcome beta-blocker resistance. 2

Observation and Discharge Planning

• Observe for minimum 4–6 hours after symptom resolution, with longer observation for severe reactions, persistent airway symptoms, or patients requiring multiple epinephrine doses. 1
• Prescribe two epinephrine auto-injectors (0.3 mg for adults) with hands-on training. 1
• Discharge with prednisone 1 mg/kg daily (maximum 60–80 mg) for 2–3 days to cover the window for biphasic reactions. 1
• Provide H1-antihistamine and H2-antihistamine for 2–3 days. 1
• Schedule follow-up with allergist within 1–2 weeks for formal testing and long-term management plan. 1

Critical Pitfalls to Avoid

• Never delay or substitute epinephrine with corticosteroids or antihistamines—epinephrine is the only medication that treats acute anaphylaxis. 1
• Do not use IV epinephrine initially unless the patient is in refractory shock despite IM epinephrine and fluids; IV epinephrine requires 1:10,000 dilution (0.05–0.1 mg slowly) to prevent fatal arrhythmias. 1
• Ensure proper IM injection technique for Kenalog—inject deeply into gluteal muscle to avoid subcutaneous fat atrophy. 3
• Do not discharge prematurely—biphasic reactions can occur up to 72 hours after initial presentation. 2, 1