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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
- 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 gouty arthritis.
- 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 shoulder is essentially a non-weight-bearing joint, the chance of
provoking a steroid arthropathy is virtually non existent.
However, in the treatment of shoulder lesions with triamcinolone the recommended dose and interval should not be
- 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.