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General side effects
There are considerably fewer side effects after intra
articular injections of 20 mg triamcinolone than produced after
the systemic administration of the same dose . However, the
following side effects are possible:
- Hyperglycaemia. Glucocorticoids have an important
influence on the intermediary metabolism. They increase
circulatory glucose via stimulation of gluconeogenesis
and decrease the intracellular use of glucose.
Therefore it is wise to warn diabetic patients for an
increase of their blood sugar during the first few days
after the local injection of triamcinolone.
- Slight suppression of the adrenal cortex after
prolonged administration of corticosteroids Some cortical
suppression seems to occur not only when steroids are
administered orally but also after intra-articular
injections. Prolonged administration renders the adrenals
atrophic and provokes suprarenal insufficiency with
symptoms such as hypotension, anorexia, fever and
generalized joint or muscular pain.
- Iatrogenic Cushing' s syndrome. The full syndrome
with weight gain, depression, insomnia, amenorrhoea,
diminished libido, thinned skin, muscular weakness,
polyuria and polydypsia is seldom encountered after local
use of triamcinolone. Occasionally facial hirsutism and
acne may be seen.
- Interference with the menstrual cycle. In female
patients repeated injections with steroid may lead to
dysfunctional uterine bleeding. Steroids may also
interfere with hormonal contraceptives. There is no
evidence for a teratogenic effect
- Flushing. In the first few days after an
intra-articular injection, some patients suffer from
erythema and warmth in face, neck and chest. This is a
totally benign but rather frequent sensation which is
more common after the use of triamcinolone.
- Osteoporosis and increased risk of fractures. It
is difficult to estimate the exact incidence of
osteoporosis provoked by corticosteroids. Nevertheless,
special care should be taken when administering them to
Postmenopausal females because of the increased
likelihood of these side effects.
- Allergic and anaphylactic reactions are extremely
rare: rash, or bronchospasm and hypotension are the
warning signs. Usually the additive
carboxymethylcellulose and not the triamcinolone is
responsible for the reaction. Sodium
carboxymethylcellulose is widely used in the food and
pharmaceutical industry as a suspending agent for
insoluble powders in aqueous preparations
Local Side Effects
- Iatrogenic infectious arthritis. This
life-treathening complication is the most feared although
it is seldom encountered - iatrogenic infectious
arthritis follows one in 14.000-50.000 injections.
Obviously this complication should be avoided by good
antiseptic care, especially when the injection is made
into a high-risk patient and when infiltrating in the
neighbourhood of a joint or in the joint itself.
- Flare up of crystal-induced arthritis. During the
first 48 hours after an intra-articular injection of a
crystalline suspension, a synovitis may flare up as
response to the crystals. The mechanism is the same as in
- Destruction of joint cartilage and evolution of
steroid arthropathy. Because steroids depress the
synthesis of collagen and proteoglycans, which may result
in a loss of stiffness of the cartilage, it has been
suggested that intra-articular steroids may hasten the
process of arthrosis by a deleterious effect on
cartilage.However, the concept of 'corticosteoid
arthropathy' is based largely on subprimate animal
studies and several anectodical case reports. Limited
investigations of primate models have shown no
significant long-term deleterious effect on cartilage.
Furthermore, since the elbow is essentially a
non-weight-bearing joint, the chance of provoking a
steroid arthropathy is virtually non existent.
However, in the treatment of elbow lesions with
triamcinolone the recommended dose and interval should
not be surpassed.
- Fat necrosis and skin atrophy. These side effects
are due to a faulty injection technique or to leakage of
the product after an intra-articular injection.