Triamcinolone/kenalog

Hi Nikki. According to a couple of sources, the comparative potency of steroids is as follows (using cortisone as a baseline of 1)

Hydrocortisone - 1.2

Prednisolone - 5

Triamcinolone - 6

Methylprednisolone - 6

Dexamethasone - 35

Betamethasone - 35

So, roughly speaking, 30mg of pred would be equivalent to about 25mg of triamcinolone, when given by the same route (oral, IM, IV etc).

Hi koolcat,

Don't worry, it doesn't sound daft at all - although I know the normal and maximum doses for triamcinolone, I'm not entirely sure of the direct conversion myself, and it's surprisingly difficult to find the right information on the web. I'll try to answer as best as I can - I hope it doesn't end up being more confusing.

The BNF lists 4mg of triamcinolone as being roughly equivalent to 5mg of prednisolone, meaning that 80mg of depot triamcinolone would be equivalent to 100mg of prednisolone. The BNF comments that this does not take into account the duration of action - since triamcinolone acetonide (Kenalog) has a duration of action of four to six weeks, I interpret this as meaning that 80mg of depot trimacinolone every four weeks would be equivalent to 100mg of prednisolone DAILY for four weeks. The alternative interpretation would be that 80mg of depot triamcinolone four weekly is equivalent to 100mg of prednisolone spread over four weeks, or roughly 3.5mg daily, which seems like an unrealistically small dose.

Other sources, though, site evidence that triamcinolone ACETONIDE, specifically (which is the specific functional group of triamcinolone that is in Kenalog) has been shown to be up to eight times stronger than prednisolone in animal models - ie, that 1mg of triamcinolone acetonide would be equivalent to 8mg of prednisolone. This would mean that 80mg of depot triamcinolone would be equivalent to 640mg of prednisolone, presumably spread over the four weeks, which would give a dose of 80mg of prednisolone daily.

Either way, I'm guessing that as a ball-park figure, 80mg depot triamcinolone over four weeks might be considered to be roughly equivalent to 80 - 100mg of prednisolone per day. This is only a guess, though! - I have to say that reading the different interpretations of the conversion calculation on the web has me a little confused.

From my clinical experience of using triamcinolone (which is not particularly extensive, I will admit) that would seem about right - certainly, folks are usually on a fairly hefty dose of prednisolone before they get converted to depot triamcinolone.

80 - 100mg of prednisolone a day might sound like a horrendously high dose - but remember that triamcinolone has a slightly different side effect profile than prednisolone, and some of the more worrisome side effects of prednisolone often seem to occur less frequently with triamcinolone. It also appears to be more effective in asthma control in some people, for reasons that are not fully understood.

As I say, all of this is guesswork and conjecture, so please don't take it as fact. I'll try to ask my friendly neighbourhood rheumatologist, if I get a chance, and if you do end up asking Jayden's consultant, I'd be interested to hear the answer.

Take care,

Em

Hmmm, just noticed CathBear's version, sounds a lot simpler than mine! Think I might have over-complicated things - sorry! :S

To be fair, Em, you've probably answered the actual question being asked!

Nikki it's not daft Sean been on kenalog since April and I often wondered what the conversion was and keep forgetting to ask! I've been told by Prof at Rbh that its given for 3 mths and that the dose is so high that its too much risk to be on it for any longer. Sean has had 9 80mg jabs since april and still been symptomatic and needed extra pred courses on top. If the conversion is equiv to 100mg day no wonder his con been desperately trying to get his dose down. The only plus side is Sean hasnt got bloated belly on kenalog like he does on pred. He is on month 3 of top dose Aziathropine as steroid sparing so hoping we can reduce kenalog asap. Sean was only meant to have 3 jabs, none of us imagined he would need so many at that dose. I really hope kenalog works for Jayden.

J x

Meant to say We are at Rbh again in 2 weeks so i'll ask his con and let you know if you dont get answer sooner.

Jx

Thanks for the replys, both very helpful.

Cath - thanks for conversion table. No wonder Jay is looking a little like a cabbage patch doll (he won't thank me for that!)

Emily - Thanks for helping me understand the amount given each day, I agree 3.5mg a day sounds a bit pointless and probably wouldn't make Jay look as if he's gob stoppers all the time.

Julie - Let us know if you find out, thanks.

Lol @ cabbage patch doll, Seans cheeks go up and down at random each month.

Just had a thought if using the assumption more than 40mg a day of pred is not effective why would they give equiv of 100mg??? But then answering my own question I guess it same as Rbh giving dexmethsone as inpatient at pred equiv of 225mg per day. I def agree 3.5 mg per day wouldnt produce the cheeks we have going on here at mo. Ok i'm wandering off now trying to figure why on earth Sean has needed equiv 100 mg daily for 7 mth.

I'm not 100% sure about it being equivalent to 100mg a day, but it is the explanation that seems to make most sense - certainly 3.5mg a day wouldn't produce the symptoms you're describing - it's less than the body's own endogenous steroid production!

I know that RBH and a lot of places say that there is no real value in giving more than 40mg of pred a day - but I think that varies for different steroids. The dose-response curve in asthma does plateau at high doses, but the specific dose at which it plateaus varies for different steroids. For example, for fluticasone it's about 2000 mcg per day - there's no evidence that going higher than this improves control at all.

I know when I was in RBH for the Difficult Asthma Protocol and I had an acute splatt, they had me on 200mg of hydrocortisone four times a day for about ten days - that's equivalent to 200mg of pred a day! I think they would have continued it for longer if it hadn't been for the fact that I was determined to get home for Christmas. I don't react well to IV hydrocort, to say the least, either physically or psychologically, and by the end of the ten days I was swelling up all over, had a blood pressure of 193/117 and was climbing the walls! Thank goodness my local will change back to oral pred as soon as they are happy that you can keep tablets down.

Anyway, I hope you both get some answers about the Kenalog dose, and that things are reasonably stable; do let us know, won't you?

Take care all

Em