Any place for depot triamcinolone in hay fever?
Relevant BNF section: 6.3.2
The prevalence of hay fever (seasonal allergic rhinitis) in the UK has been increasing; for instance, it doubled from 10 to 20 per 1000 people between the 1970s and 1980s.1 For a few patients with severe hay fever symptoms, it sometimes helps to give a systemic corticosteroid; one possible option is the injection of a long-acting corticosteroid, such as triamcinolone. We have previously concluded that systemic corticosteroids have only a limited role, that is, when complete control of severe symptoms is judged essential (e.g. for a wedding or exam).2 Here we reconsider the case for depot triamcinolone injections in the management of hay fever.
While it is not always possible for people with hay fever to avoid pollens that usually trigger their symptoms, potentially helpful measures include avoiding high-pollen areas, keeping windows shut and using high-efficiency particulate filters in cars. Susceptible people should avoid walking in open grassy spaces, particularly during the evening and at night when pollen counts are highest.3,4
Both the international and UK guidelines recommend that if allergen avoidance fails to control symptoms, treatment with a topical or oral antihistamine should be used as required, or topical sodium cromoglycate used regularly.3,4 Where these treatments are ineffective, regular intranasal corticosteroids should be used, with oral or topical antihistamines added if needed. Intranasal corticosteroid preparations are more effective than oral antihistamines in relieving most hay fever nasal symptoms.5 Moreover, intranasal corticosteroids are as effective as oral antihistamines for relieving eye symptoms.5 Treatment with topical corticosteroids may be more effective if it is started before the hay fever season begins. If nasal congestion is established, pretreatment with topical decongestants for up to a week may allow better penetration of topical corticosteroids, potentially increasing their efficacy.
Occasionally, for patients with severe symptoms (e.g. nasal blockage severe enough to render nasal sprays ineffective, or when stringent control of symptoms is required), it may be reasonable to supplement maintenance intranasal corticosteroids plus oral antihistamines with a brief course of oral corticosteroids.3,4 These should, however, only be used in the lowest effective dose (e.g. prednisolone up to 20mg daily for up to 5 days). Both the international and the UK guidelines advise against the use of injectable corticosteroids in hay fever.3,4
Use of triamcinolone injections
Triamcinolone (Kenalog - Squibb) is a corticosteroid which can be given as an intramuscular depot injection. A 4mg dose of triamcinolone has anti-inflammatory activity equivalent to that of about 5mg of prednisolone.6 Triamcinolone is commonly used to treat hay fever in UK general practice; for example, in the Wessex region in 1994/5, 11% of hay fever sufferers were treated with a depot corticosteroid injection (usually triamcinolone).7 Typical situations for which GPs use an injectable steroid include where there is: insufficient relief from other treatments; a social or work circumstance requiring stringent symptom control; unwillingness of the patient to take daily treatments; and non-adherence to other therapy.
The licensed indications for intramuscular triamcinolone injection include use "in seasonal allergies" in "patients who do not respond to conventional therapy". The summary of product characteristics (SPC) states that treatment "may achieve a remission of symptoms over the entire period with a single intramuscular injection". The manufacturer recommends a single 40-100mg dose administered deep into the gluteal muscle when symptoms of hay fever appear.
In the only published randomised, double-blind, placebo-controlled trial, 38 patients with severe symptoms of hay fever received either an intramuscular injection of triamcinolone 40mg or placebo. After 10 days, symptoms had improved or resolved in 16 of 17 (94%) patients given triamcinolone compared with 2 of 21 (10%) of those given placebo.8
In a double-blind trial, 220 patients with acute allergic conditions (43% with hay fever, most others with asthma), received an injection of either triamcinolone 40mg or dexamethasone 8mg, while continuing any symptomatic treatment (e.g. decongestants or antihistamine) or antibiotic therapy.9 Whether treatments were randomly assigned is unclear from the trial report. Triamcinolone and dexamethasone appeared similarly effective in alleviating features of allergic disease (74% of those on triamcinolone vs. 66% on dexamethasone had a 'good' or 'excellent' response). Clinical benefits began within 8 hours for around two-thirds of those who received either drug, and in most of these lasted for less than 4 days. No subgroup results were reported for the patients with hay fever.
Evidence from other studies
In an uncontrolled study involving 50 patients with hay fever (severe in about 50%), treatment with a single 80mg dose of intramuscular triamcinolone at symptom onset was associated with complete or partial relief of symptoms in 94% of people within 3 days.10 Treatment benefit lasted throughout the season in 26% of patients, 1-2 months in 52%, 1 month in 20% and 1 week in 2%. In another uncontrolled study, 418 patients with a variety of allergic disorders (including asthma, bronchitis, rhinitis and sinusitis) were given a single triamcinolone injection in doses of 40-100mg.11 The average duration of effect was around 40 days.
No study has compared triamcinolone injection with oral or intranasal corticosteroid therapy in hay fever alone.
Triamcinolone given intramuscularly might cause any of the unwanted effects of systemic corticosteroids. These include suppression of the hypothalamo-pituitary-adrenal (HPA) axis, osteoporosis, menstrual irregularity, glucose intolerance and increased susceptibility to infection. There is a marked lack of controlled trial data on the likelihood of such effects when triamcinolone injections are used to treat hay fever.
In a randomised, double-blind trial, 97 patients with hay fever or vasomotor rhinitis were given a single intramuscular injection of either triamcinolone 40mg or placebo.8 In all, 2 out of 38 patients who were given triamcinolone complained of menstrual disturbance and 2 others reported local tenderness after injection.
Indirectly-relevant data regarding repeated administration come from a randomised double-blind cross-over study of 20 patients (12 women) with severe chronic asthma treated with intramuscular triamcinolone 80mg once every 4 weeks or with oral prednisolone 10mg daily for 24 weeks.12 In all, 18 of the 20 (90%) patients treated with triamcinolone reported unwanted effects compared with 12 of 20 (60%) on prednisolone; no statistical analysis of these results was reported. The most common effects were muscle aching and weakness (6 patients with triamcinolone vs. 2 with prednisolone), and rash (5 vs. 2, respectively). In all, 3 out of 4 premenopausal women developed amenorrhoea or menorrhagia on triamcinolone compared with none on prednisolone. One postmenopausal patient developed vaginal bleeding after receiving two triamcinolone injections.
Effects on adrenal function
In an uncontrolled study, 18 patients with hay fever (which had responded poorly to other treatments) received a single 80mg injection of triamcinolone.13 Estimations of basal cortisol concentration showed depression of the HPA axis, beginning within 24 hours of the injection. Within 3 weeks, basal cortisol concentrations had returned to the pretreatment levels. By contrast, following administration of prednisone 25mg twice daily for 5 days, HPA function in 10 healthy men returned to near-normal by 5 days later.14
In patients with severe hay fever, in whom there are compelling reasons to obtain symptom control (e.g. a wedding or exam), it is worth trying a brief course of oral prednisolone; this approach allows flexibility in dosing and the option to stop treatment if unwanted effects occur.
A single intramuscular depot injection of triamcinolone is likely to relieve hay fever symptoms. However, it is unclear for how long any benefit is likely to last, what unwanted effects might develop and how triamcinolone compares with standard therapy. Until there is clear evidence of its advantages over other hay fever treatments, including oral prednisolone, use of depot injections of triamcinolone is no longer acceptable. The licences covering this indication for triamcinolone and other depot corticosteroid injections should be reviewed.
[M=meta-analysis; R=randomised controlled trial]