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CLINICAL PHARMACOLOGY Mechanism of Action Triamcinolone acetonide is a synthetic fluorinated corticosteroid with approximately 8 times the potency of prednisone in animal models of inflammation. Although the precise mechanism of corticosteroid antiallergic action is unknown, corticosteroids have been shown to have a wide range of actions on multiple cell types (e.g., mast cells, eosinophils, neutrophils, macrophages, lymphocytes) and mediators (e.g., histamine, eicosanoids, leukotrienes, cytokines) involved in inflammation. Pharmacodynamics In order to determine if systemic absorption plays a role in the effect of NASACORT AQ Nasal Spray on allergic rhinitis symptoms, a two week double-blind, placebo-controlled clinical study was conducted comparing NASACORT AQ, orally ingested triamcinolone acetonide, and placebo in 297 adult patients with seasonal allergic rhinitis. The study demonstrated that the therapeutic efficacy of NASACORT AQ Nasal Spray can be attributed to the topical effects of triamcinolone acetonide. Adrenal Function In order to evaluate the effects of systemic absorption on the Hypothalamic-Pituitary-Adrenal (HPA) axis, 4 clinical studies, one each in adults and in children 6-12 years of age, 2-5 years of age, and 2-11 years of age, were conducted. The adult clinical study compared 220 mcg or 440 mcg NASACORT AQ per day, or 10 mg prednisone per day with placebo for 42 days. Adrenal response to a six-hour 250 mcg cosyntropin stimulation test showed that NASACORT AQ administered at doses of 220 mcg and 440 mcg had no statistically significant effect on HPA activity versus placebo. Conversely, oral prednisone at 10 mg/day significantly reduced the response to ACTH. A study evaluating plasma cortisol response thirty and sixty minutes after 250 mcg cosyntropin stimulation in 80 pediatric patients 6 to 12 years of age who received 220 mcg or 440 mcg (twice the maximum recommended daily dose) daily for six weeks was conducted. No abnormal response to cosyntropin infusion (peak serum cortisol < 18 mcg/dL) was observed in any pediatric patient after six weeks of dosing with NASACORT AQ at 440 mcg per day. In pediatric patients 2 to 5 years of age (n = 61) receiving Nasacort AQ 110 mcg per day intranasally, HPA axis function was assessed by cosyntropin stimulation test; however, the results were inconclusive. An effect of Nasacort AQ Nasal Spray on adrenal function in children 2 to 5 years of age cannot be ruled out. In a 6-week trial in 140 children 2 to 11 years of age with allergic rhinitis, a daily dose of 110 or 220 mcg of NASACORT AQ Nasal Spray was compared to placebo nasal spray. A subset of 24 children 6 to 11 years of age received a higher dose of 220 mcg of NASACORT AQ Nasal Spray. A positive control was not included in this trial. Adrenal function was assessed by measurement of 24 hour serum cortisol levels before and after the treatment. The difference from placebo in the change from baseline in LS mean serum cortisol AUC (0-24 hr) at the end of week 6 for the NASACORT AQ Nasal Spray treatment groups (110 mcg and 220 mcg) was -4.2 mcg•hour/dL (95% CI: -14.7, 6.4). Pharmacokinetics Based upon intravenous dosing of triamcinolone acetonide phosphate ester in adults, the half-life of triamcinolone acetonide was reported to be 88 minutes. The volume of distribution (Vd) reported was 99.5 L (SD ± 27.5) and clearance was 45.2 L/hour (SD ± 9.1) for triamcinolone acetonide. The plasma half-life of corticosteroids does not correlate well with the biologic half-life. Pharmacokinetic characterization of the NASACORT AQ Nasal Spray formulation was determined in both normal adult subjects and patients with allergic rhinitis. Single dose intranasal administration of 220 mcg of NASACORT AQ Nasal Spray in normal adult subjects and patients demonstrated minimal absorption of triamcinolone acetonide. The mean peak plasma concentration was approximately 0.5 ng/mL (range: 0.1 to 1.0 ng/mL) and occurred at 1.5 hours post dose. The mean plasma drug concentration was less than 0.06 ng/mL at 12 hours, and below the assay detection limit (the minimum LOQ of the assay was 0.025 ng/ml) at 24 hours. The average terminal half-life was 3.1 hours. The range of mean AUC0–∞ values was 1.4 ng•hr/mL to 4.7 ng•hr/mL between doses of 110 mcg to 440 mcg in both patients and healthy volunteers. Dose proportionality was demonstrated in both normal adult subjects and in allergic rhinitis patients following single intranasal doses of 110 mcg or 220 mcg NASACORT AQ Nasal Spray. The Cmax and AUC0-∞ of the 440 mcg dose increased less than proportionally when compared to 110 and 220 mcg doses. Following multiple dose administration of NASACORT AQ 440 mcg once daily in pediatric patients 6 to 12 years of age, plasma drug concentrations, AUC0-∞, Cmax and Tmax were similar to those values observed in adult patients receiving the same dose. Intranasal administration of NASACORT AQ 110 mcg once daily in pediatric patients 2 to 5 years of age exhibited similar systemic exposure to that achieved in adult patients 20 to 49 years of age with intranasal administration of NASACORT AQ at a dose of 220 mcg once daily. Based on the population pharmacokinetic modeling, the apparent clearance and volume of distribution following intranasal administration of NASACORT AQ in pediatric patients 2 to 5 years of age were found to be approximately half of that in adults. In animal studies using rats and dogs, three metabolites of triamcinolone acetonide have been identified. They are 6β-hydroxytriamcinolone acetonide, 21-carboxytriamcinolone acetonide and 21-carboxy-6β-hydroxytriamcinolone acetonide. All three metabolites are expected to be substantially less active than the parent compound due to (a) the dependence of anti-inflammatory activity on the presence of a 21-hydroxyl group, (b) the decreased activity observed upon 6-hydroxylation, and (c) the markedly increased water solubility favoring rapid elimination. There appeared to be some quantitative differences in the metabolites among species. No differences were detected in metabolic pattern as a function of route of administration. Animal Toxicology and/or Pharmacology Triamcinolone acetonide was teratogenic in rats, rabbits, and monkeys. In rats, triamcinolone acetonide was teratogenic at an inhalation dose of 20 mcg/kg and above (approximately 7/10 of the maximum recommended daily intranasal dose in adults on a mcg/m² basis). In rabbits, triamcinolone acetonide was teratogenic at inhalation doses of 20 mcg/kg and above (approximately 2 times the maximum recommended daily intranasal dose in adults on a mcg/m² basis). In monkeys, triamcinolone acetonide was teratogenic at an inhalation dose of 500 mcg/kg (approximately 37 times the maximum recommended daily intranasal dose in adults on a mcg/m² basis). Dose-related teratogenic effects in rats and rabbits included cleft palate and/or internal hydrocephaly and axial skeletal defects, whereas the effects observed in the monkey were cranial malformations. Hypoadrenalism may occur in infants born of mothers receiving corticosteroids during pregnancy. Such infants should be carefully observed. Clinical Studies The safety and efficacy of NASACORT AQ Nasal Spray have been evaluated in 10 double-blind, placebo-controlled clinical studies of two-to four-weeks duration in adults and children 12 years and older with seasonal or perennial allergic rhinitis. The number of patients treated with NASACORT AQ Nasal Spray in these studies was 1266; of these patients, 675 were males and 591 were females. Overall, the results of these clinical studies in adults and children 12 years and older demonstrated that NASACORT AQ Nasal Spray 220 mcg once daily (2 sprays in each nostril), when compared to placebo, provides statistically significant relief of nasal symptoms of seasonal or perennial allergic rhinitis including sneezing, stuffiness, discharge, and itching. The safety and efficacy of NASACORT AQ Nasal Spray, at doses of 110 mcg or 220 mcg once daily, have also been adequately studied in two double-blind, placebo-controlled studies of two-and twelve-weeks duration in children ages 6 through 12 years with seasonal and perennial allergic rhinitis. These studies included 341 males and 177 females. NASACORT AQ administered at either dose resulted in statistically significant reductions in the severity of nasal symptoms of allergic rhinitis. The safety and efficacy of NASACORT AQ Nasal Spray in children 2 to 5 years of age with perennial allergic rhinitis with or without seasonal allergic rhinitis was studied in a single 4 week double blind, placebo controlled clinical study with a 24 week open label extension conducted in the United States. The study included 464 patients (266 males and 198 females) 2 to 5 years of age who received at least one dose of study medication (233 placebo, 231 NASACORT AQ 110 mcg once daily). Efficacy was determined over a four-week double-blind, placebo-controlled treatment period and was based on patient's parent or guardian recording of four nasal symptoms (total nasal symptom score, TNSS), congestion, itching, rhinorrhea, and sneezing on a 0-3 categorical severity scale (0=absent, 1=mild, 2=moderate, and 3=severe) once daily. Reflective scoring (rTNSS) required recording symptom severity over the previous 24 hours; the instantaneous scoring (iTNSS) required recording symptom severity at the time just prior to dosing. Baseline symptom severity was comparable between NASACORT AQ and placebo respectively, for iTNSS (7.52, 7.61) and rTNSS (7.96, 7.87). While the 24-hour iTNSS over the 4-week double-blind period was numerically improved with NASACORT AQ (-2.28) vs. placebo (-1.92), the difference was not statistically significant (difference from placebo -0.36; 95% CI [-0.77, 0.06]; p value = 0.095). For the 24-hour rTNSS over the 4 week double-blind treatment period, NASACORT A Q 110 mcg once daily provided statistically significantly greater improvement from baseline (-2.31) versus placebo (-1.87) (difference from placebo 0.44; 95% CI [-0.84, -0.04]; p value = 0.033).

CLINICAL PHARMACOLOGY Triamcinolone acetonide is a more potent derivative of triamcinolone. Although triamcinolone itself is approximately one to two times as potent as prednisone in animal models of inflammation, triamcinolone acetonide is approximately 8 times more potent than prednisone. The precise mechanism of the action of glucocorticoids in asthma is unknown. However, the inhaled route makes it possible to provide effective local anti-inflammatory activity with reduced systemic corticosteroid effects. Though highly effective for asthma, glucocorticoids do not affect asthma symptoms immediately. While improvement in asthma may occur as soon as one week after initiation of Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol therapy, maximum improvement may not be achieved for 2 weeks or longer. Based upon intravenous dosing of triamcinolone acetonide phosphate ester, the half-life of triamcinolone acetonide was reported to be 88 minutes. The volume of distribution (Vd) reported was 99.5 L (SD ± 27.5) and clearance was 45.2 L/hour (SD ± 9.1) for triamcinolone acetonide. The plasma half-life of glucocorticoids does not correlate well with the biologic half-life. The pharmacokinetics of radiolabeled triamcinolone acetonide [14C] were evaluated following a single oral dose of 800 mcg to healthy male volunteers. Radiolabeled triamcinolone acetonide was found to undergo relatively rapid absorption following oral administration with maximum plasma triamcinolone acetonide and [14C]-derived radioactivity occurring between 1.5 and 2 hours. Plasma protein binding of triamcinolone acetonide appears to be relatively low and consistent over a wide plasma triamcinolone acetonide concentration range as a function of time. The overall mean percent fraction bound was approximately 68%. The metabolism and excretion of triamcinolone acetonide were both rapid and extensive with no parent compound being detected in the plasma after 24 hours post-dose and a low ratio (10.6%) of parent compound AUC0-∞ to total [14C] radioactivity AUC0-∞. Greater than 90% of the oral [14C]-radioactive dose was recovered within 5 days after administration in 5 out of the 6 subjects in the study. Of the recovered [14C]-radioactivity, approximately 40% and 60% were found in the urine and feces, respectively. Three metabolites of triamcinolone acetonide have been identified. They are 6β- hydroxytriamcinolone acetonide, 21-carboxytriamcinolone acetonide and 21-carboxy-6β- hydroxytriamcinolone acetonide. All three metabolites are expected to be substantially less active than the parent compound due to (a) the dependence of anti-inflammatory activity on the presence of a 21-hydroxyl group, (b) the decreased activity observed upon 6-hydroxylation, and (c) the markedly increased water solubility favoring rapid elimination. There appeared to be some quantitative differences in the metabolites among species. No differences were detected in metabolic pattern as a function of route of administration. Clinical Trials Double-blind, placebo-controlled efficacy and safety studies have been conducted in asthma patients with a range of asthma severities, from those patients with mild disease to those with severe disease requiring oral steroid therapy. The efficacy and safety of Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol given twice daily was demonstrated in two placebo-controlled clinical trials. In two separate studies, 222 asthmatic patients were randomized to receive either Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol 300 mcg twice daily or matching placebo for a treatment period of 6 weeks. Patients were adult asthmatics who were using inhaled beta2-agonists on more than an occasional basis (at least three times weekly), either without or with inhaled corticosteroids, for control of their asthma symptoms. For the combined studies, 48% (52/109) patients randomized to placebo and 41% (46/113) patients randomized to Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol treatment were previously treated with inhaled corticosteroids. Results of weekly lung function tests (FEV1) from one of these trials is presented graphically below. Results of the second study are presented in tabular form as the changes in asthma measures from baseline to the end of the treatment period. Mean Changes in Asthma Measures from Baseline to Endpointa All-Treated Patients Results from a Placebo-Controlled, 6 Week Study Asthma Measure Placebo (N=61) Azmacort 300 mcg bid (N=60) Percent Change in FEV1(%) 2.8% 17.5% Increase in Morning Peak 6.7 45.9 Flow Rate (L/min) Decrease in Albuterol Use 0.6 3.4 (puffs/day) Decrease in Daily Asthma Symptom Score (units/day)b 0.5 2.3 aEndpoint results are obtained from the last evaluable data, regardless of whether the patient completed 6 weeks of treatment bScale (0-6) with 0 = no symptom: Maximum Score (AM + PM) =12 In both studies, treatment with Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol (300 mcg twice daily) resulted in significant improvements in all clinical asthma measures (lung functions, asthma symptoms, use of as-needed beta2-agonist medications) when compared to placebo.

Find Lowest Prices on Nasacort® AQ (triamcinolone acetonide) Nasal Spray DESCRIPTION Triamcinolone acetonide, USP, the active ingredient in NASACORT AQ Nasal Spray, is a corticosteroid with a molecular weight of 434.51 and with the chemical designation 9-Fluoro11β,16α,17,21-tetrahydroxypregna-1,4-diene-3,20-dione cyclic 16,17-acetal with acetone (C24H31FO6). NASACORT AQ Nasal Spray is a thixotropic, water-based metered-dose pump spray formulation unit containing a microcrystalline suspension of triamcinolone acetonide in an aqueous medium. Microcrystalline cellulose, carboxymethylcellulose sodium, polysorbate 80, dextrose, benzalkonium chloride, and edetate disodium are contained in this aqueous medium; hydrochloric acid or sodium hydroxide may be added to adjust the pH to a target of 5.0 within a range of 4.5 and 6.0.

Azmacort® (triamcinolone acetonide) Inhalation Aerosol For Oral Inhalation Only Shake Well Before Using DESCRIPTION Proprietary name: Azmacort Established name: Triamcinolone acetonide Route of administration: RESPIRATORY (INHALATION) (C38216) Active ingredients (moiety): Triamcinolone acetonide (Triamcinolone) # Strength Form Inactive ingredients 1 60 MILLIGRAM AEROSOL, METERED (C42960) Dehydrated alcohol, dichlorodifluoromethane Triamcinolone acetonide, USP, the active ingredient in Azmacort® (triamcinolone acetonide inhalation aerosol) Inhalation Aerosol, is a corticosteroid with a molecular weight of 434.5 and with the chemical designation 9- Fluoro-11β,16α,17,21-tetrahydroxypregna-1,4-diene-3,20-dione cyclic 16,17-acetal with acetone. (C24H31FO6). Azmacort (triamcinolone acetonide inhalation aerosol) Inhalation Aerosol is a metered-dose aerosol unit containing a microcrystalline suspension of triamcinolone acetonide in the propellant dichlorodifluoromethane and dehydrated alcohol USP 1% w/w. Each canister contains 60 mg triamcinolone acetonide. The canister must be primed prior to the first use. After an initial priming of 2 actuations, each actuation delivers 200 mcg triamcinolone acetonide from the valve and 75 mcg from the spacer-mouthpiece under definedin vitro test conditions. The canister will remain primed for 3 days. If the canister is not used for more than 3 days, then it should be reprimed with 2 actuations. There are at least 240 actuations in one Azmacort (triamcinolone acetonide inhalation aerosol) Inhalation Aerosol canister. After 240 actuations, the amount delivered per actuation may not be consistent and the unit should be discarded.

INDICATIONS NASACORT AQ Nasal Spray is indicated for the treatment of the nasal symptoms of seasonal and perennial allergic rhinitis in adults and children 2 years of age and older. DOSAGE AND ADMINISTRATION Administer NASACORT AQ Nasal Spray by the intranasal route only. Shake NASACORT AQ Nasal Spray well before each use. Adults and Adolescents 12 Years of Age and Older The recommended starting and maximum dose is 220 mcg per day as two sprays in each nostril once daily. Titrate an individual patient to the minimum effective dose to reduce the possibility of side effects. When the maximum benefit has been achieved and symptoms have been controlled, reducing the dose to 110 mcg per day (one spray in each nostril once a day) has been shown to be effective in maintaining control of the allergic rhinitis symptoms. Children 2 to 12 Years of Age Children 6 to 12 years of age The recommended starting dose is 110 mcg per day given as one spray in each nostril once daily. Children not responding adequately to 110 mcg per day may use 220 mcg (2 sprays in each nostril) once daily. Once symptoms have been controlled, the dosage may be decreased to 110 mcg once daily [see WARNINGS AND PRECAUTIONS, Use In Specific Populations and CLINICAL PHARMACOLOGY]. Children 2 to 5 years of age The recommended and maximum dose is 110 mcg per day given as one spray in each nostril once daily [see WARNINGS AND PRECAUTIONS, Use in Specific Populations and CLINICAL PHARMACOLOGY]. NASACORT AQ Nasal Spray is not recommended for children under 2 years of age. Administration Information Priming Prime NASACORT AQ Nasal Spray before using for the first time by shaking the contents well and releasing 5 sprays into the air away from the face. It will remain adequately primed for two weeks. If the product is not used for more than 2 weeks, then it can be adequately reprimed with one spray. Shake NASACORT AQ Nasal Spray well before each use. If adequate relief of symptoms has not been obtained after 3 weeks of treatment, NASACORT AQ Nasal Spray should be discontinued [see WARNINGS AND PRECAUTIONS, PATIENT INFORMATION, and ADVERSE REACTIONS]. HOW SUPPLIED Dosage Forms And Strengths NASACORT AQ Nasal Spray is a metered-dose pump spray containing the active ingredient triamcinolone acetonide. Each actuation delivers 55 mcg triamcinolone acetonide from the nasal actuator after an initial priming of 5 sprays. Each 16.5 gram bottle (120 actuations) contains 9.075 mg of triamcinolone acetonide. The bottle should be discarded when the labeled-number of actuations have been reached even though the bottle is not completely empty. Storage And Handling NASACORT AQ Nasal Spray, 55 mcg per spray, is supplied in a white high-density polyethylene container with a metered-dose pump unit, white nasal adapter, and patient instructions (NDC 0075-1506-16). The contents of one 16.5 gram bottle provide 120 actuations. After 120 actuations, the amount of triamcinolone acetonide delivered per actuation may not be consistent and the unit should be discarded. Each actuation delivers 55 mcg triamcinolone acetonide from the nasal actuator after an initial priming of 5 sprays [see DOSAGE AND ADMINISTRATION Information]. In the Patient Package Information, patients are provided with a check-off form to track usage [see PATIENT INFORMATION]. Keep out of reach of children. Storage Store at Controlled Room Temperature, 20 to 25°C (68 to 77°F) sanofi-aventis U.S. LLC Bridgewater, NJ 08807 A Sanofi Company. Revised: July 2013

INDICATIONS Azmacort (triamcinolone acetonide) Inhalation Aerosol is indicated in the maintenance treatment of asthma as prophylactic therapy. Azmacort (triamcinolone acetonide) Inhalation Aerosol is also indicated for asthma patients who require systemic corticosteroid administration, where adding Azmacort (triamcinolone acetonide) Inhalation Aerosol may reduce or eliminate the need for the systemic corticosteroids. Azmacort (triamcinolone acetonide) Inhalation Aerosol is NOT indicated for the relief of acute bronchospasm. DOSAGE AND ADMINISTRATION Adults: The usual recommended dosage is two inhalations (150 mcg) given three to four times a day or four inhalations (300 mcg) given twice daily. The maximal daily intake should not exceed 16 inhalations (1200 mcg) in adults. Higher initial doses (12 to 16 inhalations per day) may be considered in patients with more severe asthma. Children 6 to 12 Years of Age: The usual recommended dosage is one or two inhalations (75 to 150 mcg) given three to four times a day or two to four inhalations (150 to 300 mcg) given twice daily. The maximal daily intake should not exceed 12 inhalations (900 mcg) in children 6 to 12 years of age. Insufficient clinical data exist with respect to the safety and efficacy of the administration of Azmacort (triamcinolone acetonide) Inhalation Aerosol to children below the age of 6. The long-term effects of inhaled steroids, including Azmacort (triamcinolone acetonide) Inhalation Aerosol on growth are still not fully known. Rinsing the mouth after inhalation is advised. Different considerations must be given to the following groups of patients in order to obtain the full therapeutic benefit of Azmacort (triamcinolone acetonide) Inhalation Aerosol: Note : In all patients, it is desirable to titrate to the lowest effective dose once asthma stability has been achieved. Patients Not Receiving Systemic Corticosteroids: Patients who require maintenance therapy of their asthma may benefit from treatment with Azmacort (triamcinolone acetonide) Inhalation Aerosol at the doses recommended above. In patients who respond to Azmacort (triamcinolone acetonide) Inhalation Aerosol improvement in pulmonary function is usually apparent within one to two weeks after the initiation of therapy. Patients Maintained on Systemic Corticosteroids: Clinical studies have shown that Azmacort (triamcinolone acetonide) Inhalation Aerosol may be effective in the management of asthmatics dependent or maintained on systemic corticosteroids and may permit replacement or significant reduction in the dosage of systemic corticosteroids. The patient's asthma should be reasonably stable before treatment with Azmacort (triamcinolone acetonide)Inhalation Aerosol is started. Initially, Azmacort (triamcinolone acetonide) Inhalation Aerosol should be used concurrently with the patient's usual maintenance dose of systemic corticosteroid. After approximately one week, gradual withdrawal of the systemic corticosteroid is started by reducing the daily or alternate daily dose. Reductions may be made after an interval of one or two weeks, depending on the response of the patient. A slow rate of withdrawal is strongly recommended. Generally, these decrements should not exceed 2.5 mg of prednisone or its equivalent. During withdrawal, some patients may experience symptoms of systemic corticosteroid withdrawal, e.g., joint and/or muscular pain, lassitude, and depression, despite maintenance or even improvement in pulmonary function. Such patients should be encouraged to continue with the inhaler but should be monitored for objective signs of adrenal insufficiency. If evidence of adrenal insufficiency occurs, the systemic corticosteroid doses should be increased temporarily and thereafter withdrawal should continue more slowly. Inhaled corticosteroids should be used with caution when used chronically in patients receiving prednisone regimens, either daily or alternate day. (See WARNINGS.) During periods of stress or a severe asthma attack, transfer patients may require supplementary treatment with systemic corticosteroids. Directions for Use: An illustrated leaflet of patient instructions for proper use accompanies each package of Azmacort (triamcinolone acetonide) Inhalation Aerosol. HOW SUPPLIED # Name Strength Dosage Form Appearance Package Type Package Qty NDC 1 Azmacort 60MILLIGRAM AEROSOL METERED (C42960) INHALER (C16738) 6 MILLIGRAM 60598-061-60 Azmacort Inhalation Aerosol contains 60 mg triamcinolone acetonide in a 20 gram package which delivers at least 240 actuations. It is supplied with a white plastic actuator, a white plastic spacer-mouthpiece and patient's leaflet of instructions: box of one. NDC 60598-061-60. Each actuation delivers 200 mcg triamcinolone acetonide from the valve and 75 mcg from the spacer-mouthpiece under defined in vitro test conditions. Avoid spraying in eyes. For best results, the canister should be at room temperature before use. Shake well before using. CONTENTS UNDER PRESSURE. Do not puncture. Do not use or store near heat or open flame. Exposure to temperatures above 120°F may cause bursting. Never throw canister into fire or incinerator. Keep out of reach of children unless otherwise prescribed. Store at Controlled Room Temperature 20 to 25°C (68 to 77°F) [see USP]. Note: The indented statement below is required by the Federal government's Clean Air Act for all products containing or manufactured with chlorofluorocarbons (CFCs): WARNING: Contains CFC-12, a substance which harms public health and the environment by destroying ozone in the upper atmosphere. A notice similar to the above WARNING has been placed in the "Information For The Patient" portion of this package insert under the Environmental Protection Agency's (EPA's) regulations. The patient's warning states that the patient should consult his or her physician if there are questions about alternatives. Azmacort (triamcinolone acetonide)Inhalation Aerosol is a registered trademark. ©2007 Kos Pharmaceuticals, Inc. Manufactured for: Kos Pharmaceuticals, Inc. Cranbury, NJ 08512. FDA rev date: 3/13/2008

PATIENT INFORMATION Nasacort® AQ (na' za-cort) (triamcinolone acetonide) Nasal Spray These instructions provide important information about Nasacort AQ. Ask your healthcare provider or pharmacist if you have any questions. Important: For use as a nasal spray only. What is Nasacort AQ? Nasacort®AQ Nasal Spray is a prescription medicine called a corticosteroid used to treat nasal symptoms of seasonal and year around allergies in adults and children 2 years of age and older. When Nasacort AQ is sprayed in your nose, this medicine helps to lessen the symptoms of sneezing, runny nose, nasal itching and stuffy nose. Nasacort AQ is not for children under the age of 2 years. Who should use Nasacort AQ? Do not use Nasacort AQ if you have had a reaction to triamcinolone acetonide or to any of the other ingredients in Nasacort AQ. See the end of this leaflet for a complete list of ingredients in Nasacort AQ. What should I tell my healthcare provider before using Nasacort AQ? Tell your healthcare provider if you are: pregnant or planning to become pregnant breastfeeding exposed to chickenpox or measles feeling unwell or have any symptoms that you do not understand Tell your healthcare provider about all of the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. How do I use Nasacort AQ? Use Nasacort AQ exactly as your healthcare provider tells you. You will get the best results if you use Nasacort AQ regularly and without missing a dose. Do not take extra doses. Nasacort AQ should be used as a nasal spray only. Do not spray it in your eyes or mouth. Your healthcare provider will tell you how and when to use Nasacort AQ. Do not use more Nasacort AQ or take it more often than your healthcare provider tells you. The prescription label will usually tell you how many sprays to take and how often. If it does not or if you are unsure, ask your healthcare provider or pharmacist. For people aged 12 years and older, the usual dose is 2 sprays in each nostril, one time each day. For children aged 6 to 12 years, the usual dose is 1 spray in each nostril, one time each day. Your healthcare provider may tell you to take 2 sprays in each nostril one time each day. For children aged 2 to 5 years, the usual dose is 1 spray in each nostril, one time each day. An adult should help a young child use this medicine. Do not stop taking Nasacort AQ without telling your healthcare provider. Before you throw away Nasacort AQ, talk to your healthcare provider to see if you need another prescription. If your healthcare provider tells you to continue using Nasacort AQ, throw away the empty or expired bottle and use a new bottle of Nasacort AQ. For detailed instructions, see the “Instructions for Use” at the end of this leaflet. Some symptoms may get better on the first day of treatment. It generally takes one week of use to feel the most benefit. Protect your eyes from the spray. If you get the spray in your eyes, rinse your eyes well with water. If your symptoms do not improve, or if they become worse, contact your healthcare provider. Tell your healthcare provider if you have irritation, burning or stinging inside your nose that does not go away when using Nasacort AQ. What are the possible side effects of Nasacort AQ? Common side effects of Nasacort AQ include: Sore throat, headache, and nosebleeds. If you have an increase in nosebleeds after using Nasacort AQ or the inside of your nose hurts, contact your healthcare provider. What are the other risks of using Nasacort AQ? Hole in the cartilage inside the nose (nasal septal perforation). Tell your healthcare provider if you have a whistling sound from your nose when you breathe. Fungal infection in your nose. Slow wound healing. You should not use Nasacort AQ until your nose has healed if you have a sore in your nose, if you have had surgery on your nose, or if your nose has been injured. Eye problems such as glaucoma and cataracts. Tell your healthcare provider if you have a change in vision or have a history of increased intraocular pressure, glaucoma, or cataracts. Immune system problems that may increase your risk of infections. You are more likely to get infections if you take medicines that weaken your body's ability to fight infections. Avoid contact with people who have contagious diseases such as chicken pox or measles while using Nasacort AQ. Symptoms of infection may include fever, pain, aches, chills, feeling tired, nausea and vomiting. Effect on how fast children grow. Nasacort AQ may cause your child's growth to slow down. If your child is taking Nasacort AQ, your healthcare provider will need to regularly check the height of your child and adjust the dose as appropriate. These are not all the possible side effects of Nasacort AQ. Tell your healthcare provider if you have any side effect that bothers you or that does not go away. Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088. Instructions for Use Read these instructions carefully before using your Nasacort AQ. Before using the spray pump bottle: Pull the blue cover and remove the clip from the spray pump unit. See figure A. If the top part of the spray pump comes off of the bottle when removing the cover, then re-insert the stem back into the pump. Figure A 2. Shake the spray pump bottle before each use. Priming the Spray Pump Bottle 3. Before using the spray pump bottle for the first time, it must be primed. To prime, put your thumb on the bottom of the bottle and your index and middle fingers on the “shoulders” of the bottle, and hold it upright. See figure B. Figure B 4. Point the bottle away from your eyes. Push the bottle up with your thumb and against your two fingers firmly and quickly until a fine spray appears. Do this pumping action 5 times. Now your spray pump bottle is primed and ready for use. A fine mist can only be made by a rapid and firm pumping action. 5. Repeat priming the pump, if it has not been used for more than 2 weeks. To reprime, shake the spray pump bottle and pump it just one time. Now the spray pump bottle is reprimed. Using the spray: 6. Gently blow your nose to clear it, if needed. For small children, be sure to help them gently blow their nose, as much as possible. 7. Pull off the blue cover and clip as shown in figure C. Shake the spray pump well. Figure C 8. Hold the spray pump firmly, with the index and middle finger on either side of the spray tip. Place your thumb on the bottom of the bottle. Be careful so that your fingers will not slip off the spray pump as you spray inside your nose. See figure D. Figure D 9. Put the spray tip into one side of your nose. The tip should not reach far into the nose. Rest the side of your index finger against your upper lip. Tip your head back a little and aim the spray toward the back of your nose.  See figure E. Figure E 10. Press against the other side of your nose with your finger so the nostril is closed.  Pump the spray bottle by pushing on the bottom of the bottle with your thumb firmly and quickly for the full dose of medicine. Sniff gently at the same time to help the medicine get to the back of your nose. See figure F. Repeat this step for the other side. Figure F 11. Repeat steps 8, 9 and 10 if your healthcare provider tells you to use more than one spray in each nostril. 12. Do not blow your nose for 15 minutes after using the spray. 13. After use, wipe the nozzle on the spray bottle with a clean tissue, and replace the blue cover. 14. Keep the cover and the clip on the spray pump bottle when not in use. Cleaning the spray pump bottle: 15. To clean the spray pump bottle, remove the blue cover and the spray nozzle only. Soak the cover and spray nozzle in warm water for a few minutes, and then rinse under cold water. See figure G. Figure G 16. Shake or tap off the excess water and allow to air dry. Once the cap and spray nozzle are dry, put the nozzle back onto the bottle, and prime the bottle as necessary until a fine mist is made. Use the spray as directed by your healthcare provider. If the spray bottle does not work: The hole in the tip of the nozzle may be blocked. Never try to unblock the spray hole or enlarge it with a pin or other sharp object. This will make the spray mechanism not work correctly. Changing the size of the opening can change the amount of medicine you or your child will receive. This could cause an overdose of the medicine. To clean nasal spray pump bottle, refer to Step 15. Important information Repriming the spray pump is only necessary when it has not been used for more than 2 weeks. To reprime, shake the bottle and only pump the spray bottle one time. Do not reprime if you use the spray more often than every two weeks. Each Nasacort AQ bottle contains 120 doses of medicine plus a little extra for priming the pump. A check-off chart is included with your Nasacort AQ to help you keep track of the number of sprays. This will help make sure that you receive 120 sprays of Nasacort AQ. How should I store Nasacort AQ? Store Nasacort AQ between 68° to 77°F (20° to 25° C). After using 120 sprays, throw the medicine away, as directed by your healthcare provider, even if the bottle is not empty. You may not get enough medicine if you use the bottle after 120 sprays. Keep Nasacort and all medicines out of the reach of children. General information about the safe and effective use of Nasacort AQ. Medicines are sometimes prescribed for conditions that are not mentioned in patient information. Do not use Nasacort AQ for a condition for which it was not prescribed. Do not give Nasacort AQ to other people, even if they have the same symptoms that you have. It may harm them. This leaflet summarizes the most important information about Nasacort AQ. If you would like more information, talk with your healthcare provider. You can ask your pharmacist or healthcare provider for information about Nasacort AQ that is written for health professionals. For more information call 1-800-633-1610. What are the ingredients in Nasacort AQ? Active ingredient: triamcinolone acetonide Inactive ingredients: Microcrystalline cellulose, carboxymethylcellulose sodium, polysorbate 80, dextrose, benzalkonium chloride, and edetate disodium are contained in this aqueous medium; hydrochloric acid or sodium hydroxide may be added to adjust the pH to a target of 5.0 within a range of 4.5 and 6.0.

OVERDOSE Chronic overdosage may result in signs/symptoms of hypercorticism [see WARNINGS AND PRECAUTIONS]. There are no data on the effects of acute or chronic overdosage with NASACORT AQ Nasal Spray. Because of low systemic bioavailability and an absence of acute drug-related systemic findings in clinical studies overdose is unlikely to require any therapy other than observation. Acute overdosing with the intranasal dosage form is unlikely in view of the total amount of active ingredient present and low bioavailability of triamcinolone acetonide. In the event that the entire contents of the bottle were administered all at once, via either oral or nasal application, clinically significant systemic adverse events would most likely not result. CONTRAINDICATIONS NASACORT AQ should not be administered to patients with a history of hypersensitivity to triamcinolone acetonide or to any of the other ingredients of this preparation.

OVERDOSE There are no data available on the effects of acute or chronic overdose. However, acute overdosing with Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol is unlikely in view of the total amount of active ingredient present and the route of administration. The maximum total daily dose (1200 mcg) has been well tolerated when administered as a single dose of 16 consecutive inhalations to adult asthmatics in a controlled clinical trial. Chronic overdosage may result in signs/symptoms of hypercorticoidism. (See PRECAUTIONS.) The risk of candidiasis could also be increased. CONTRAINDICATIONS Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol is contraindicated in the primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required. Hypersensitivity to triamcinolone acetonide or any of the other ingredients in this preparation contraindicates its use.

SIDE EFFECTS Systemic and local corticosteroid use may result in the following: Epistaxis, Candida albicans infection, nasal septal perforation, impaired wound healing [see WARNINGS AND PRECAUTIONS] Glaucoma and Cataracts [see WARNINGS AND PRECAUTIONS] Immunosuppression [see WARNINGS AND PRECAUTIONS] Hypothalamic-pituitary-adrenal (HPA) axis effects, including growth reduction [see WARNINGS AND PRECAUTIONS, Use in Specific Populations and CLINICAL PHARMACOLOGY] Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. In placebo-controlled, double-blind, and open-label clinical studies, 1483 adults and children 12 years and older received treatment with NASACORT AQ Nasal Spray. These patients were treated for an average duration of 51 days. In the controlled trials (2-5 weeks duration) from which the following adverse reaction data are derived, 1394 patients were treated with NASACORT AQ Nasal Spray for an average of 19 days. In a long-term, open-label study, 172 patients received treatment for an average duration of 286 days. Adverse reactions from 12 studies in adults and adolescent patients 12 to 17 years of age receiving NASACORT AQ Nasal Spray 27.5 mcg to 440 mcg once daily are summarized in Table 1. In clinical trials, nasal septum perforation was reported in one adult patient who received NASACORT AQ Nasal Spray. Table 1 : Adverse drug reactions > 2% and greater than placebo with NASACORT AQ Nasal Spray 220 mcg treatment in studies in adults and adolescents 12 years and older Adverse reaction Placebo (N=962) % NASACORT AQ 220 mcg (N=857) % Pharyngitis 3.6 5.1 Epistaxis 0.8 2.7 Cough increased 1.5 2.1 Coding dictionary for adverse events is Coding Symbols for Thesaurus of Adverse Reaction Terms (COSTART). A total of 602 children 6 to 12 years of age were studied in 3 double-blind, placebo-controlled clinical trials. Of these, 172 received 110 mcg/day and 207 received 220 mcg/day of NASACORT AQ Nasal Spray for two, six, or twelve weeks. The longest average durations of treatment for patients receiving 110 mcg/day and 220 mcg/day were 76 days and 80 days, respectively. One percent of patients treated with NASACORT AQ were discontinued due to adverse experiences. No patient receiving 110 mcg/day and one patient receiving 220mcg/day discontinued due to a serious adverse event. A similar adverse reaction profile was observed in pediatric patients 6-12 years of age as compared to adolescents and adults with the exception of epistaxis which occurred in less than 2% of the children studied. Adverse reactions from 2 studies in children 4 to 12 years of age receiving NASACORT AQ Nasal Spray 110 mcg once daily are summarized in Table 2. Table 2 : Adverse drug reactions > 2% and greater than placebo with NASACORT AQ Nasal Spray 110 mcg treatment in US studies in patients 4 to 12 years of age Adverse reaction Placebo (N=202) % NASACORT AQ 110 mcg (N=179) % Flu syndrome 7.4 8.9 Cough increased 6.4 8.4 Pharyngitis 6.4 7.8 Bronchitis 1.0 3.4 Dyspepsia 1.0 3.4 Tooth disorder 1.0 3.4 Coding dictionary for adverse events is Coding Symbols for Thesaurus of Adverse Reaction Terms (COSTART). A total of 474 children 2 to 5 years of age were studied in a 4-week double-blind, placebo-controlled clinical trial. Of these, 236 received 110 mcg/day of NASACORT AQ Nasal Spray for a mean duration of 28 days. No patient discontinued due to a serious adverse event. Adverse reactions from the single placebo-controlled study in children 2 to 5 years of age receiving NASACORT AQ Nasal Spray 110 mcg once daily are summarized in Table 3. Table 3 : Adverse drug reactions > 2% and greater than placebo with NASACORT AQ Nasal Spray 110 mcg treatment in children 2 to 5 years of age Adverse reactions Placebo (N=238)% NASACORT AQ 110 mcg (N=236) % Headache 4.2 5.5 Pharyngolaryngeal pain 4.2 5.5 Epistaxis 5.0 5.1 Nasopharyngitis 3.8 5.1 Abdominal upper pain 0.8 4.7 Diarrhea 1.3 3.0 Asthma 2.1 2.5 Rash 1.7 2.5 Excoriation 0.0 2.5 Rhinorrhea 1.7 2.1 Coding dictionary for adverse events is Medical Dictionary for Regulatory Activities terminology (MedDRA) Version 8.1 In the event of accidental overdose, an increased potential for these adverse experiences may be expected, but acute systemic adverse experiences are unlikely [see OVERDOSAGE]. Post-Marketing Experience In addition to the adverse drug reactions reported during clinical studies and listed above, the following adverse reactions have been identified during post-approval use of NASACORT AQ Nasal Spray. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Reactions that have been reported during post-marketing experience include: nasal discomfort and congestion, sneezing, alterations of taste and smell, nausea, insomnia, dizziness, fatigue, dyspnea, decreased blood cortisol, cataract, glaucoma, increased ocular pressure, pruritus, rash, and hypersensitivity. DRUG INTERACTIONS No reported drug interactions in the prescribing information.

SIDE EFFECTS The table below describes the incidence of common adverse experiences based upon three placebo-controlled, multicenter US clinical trials of 507 patients (297 female and 210 male adults (age range 18-64)). These trials included asthma patients who had previously received inhaled beta2-agonists alone, as well as those who previously required inhaled corticosteroid therapy for the control of their asthma. The patients were treated with Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol (including doses ranging from 150 to 600 mcg twice daily for 6 weeks) or placebo. Adverse Events Occurring at an Incidence of Greater Than 3% and Greater Than Placebo Adverse Event 150 mcg bid (n=57) Azmacort (triamcinolone acetonide (inhalation aerosol)) Dose 300 mcg bid (n=170) 600 mcg bid (n=57) Placebo (n=167) Sinusitis 5 (9%) 7 (4%) 1 (2%) 6 (4%) Pharyngitis 4 (7%) 42 (25%) 10 (18%) 19 (11%) Headache 4 (7%) 35 (21%) 7 (12%) 24 (14%) Flu Syndrome 2 (4%) 8 (5%) 1 (2%) 5 (3%) Back Pain 2 (4%) 3 (2%) 2 (4%) 3 (2%) Adverse events that occurred at an incidence of 1-3% in the overall Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol treatment group and greater than placebo included: Body as a whole: facial edema, pain, abdominal pain, photosensitivity Digestive system: diarrhea, oral monilia, toothache, vomiting Metabolic and Nutrition: weight gain Musculoskeletal system: bursitis, myalgia, tenosynovitis Nervous system: dry mouth Organs of special sense: rash Respiratory system: chest congestion, voice alteration Urogenital system: cystitis, urinary tract infection, vaginal monilia In older controlled clinical trials of steroid dependent asthmatics, urticaria was reported rarely. Anaphylaxis was not reported in these controlled trials. Typical steroid withdrawal effects including muscle aches, joint aches, and fatigue were noted in clinical trials when patients were transferred from oral steroid therapy to Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol. Easy bruisability was also noted in these trials. Hoarseness, dry throat, irritated throat, dry mouth, facial edema, increased wheezing, and cough have been reported. These adverse effects have generally been mild and transient. Cases of oral candidiasis occurring with clinical use have been reported. (See WARNINGS.) Cases of growth suppression have been reported for orally inhaled corticosteroids (see PRECAUTIONS, Pediatric Use section). Post Marketing: In addition to adverse events reported from clinical trials, the following events have been identified during post approval use of Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol where these events were reported voluntarily from a population of unknown size, and the frequency of occurrence cannot be determined precisely. These include rare reports of anaphylaxis, cataracts, glaucoma and very rare reports of bone mineral density loss and osteoporosis, especially with prolonged use, which may lead to an increased risk of fractures. DRUG INTERACTIONS No information provided.

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Local Nasal Effects Epistaxis In clinical studies of 2 to 12 weeks duration, epistaxis was observed more frequently in patients treated with NASACORT AQ Nasal Spray than those who received placebo [see ADVERSE REACTIONS]. Nasal Septal Perforation In clinical trials, nasal septum perforation was reported in one adult patient treated with NASACORT AQ Nasal Spray. Candida Infection In clinical studies with NASACORT AQ Nasal Spray, the development of localized infections of the nose and pharynx with Candida albicans has rarely occurred. When such an infection develops it may require treatment with appropriate local or systemic therapy and discontinuation of NASACORT AQ Nasal Spray. Therefore, patients using NASACORT AQ Nasal Spray over several months or longer should be examined periodically for evidence of Candida infection or other signs of adverse effects on the nasal mucosa. Impaired Wound Healing Because of the inhibitory effect of corticosteroids on wound healing, patients who have experienced recent nasal ulcers, surgery, or trauma should not use NASACORT AQ Nasal Spray until healing has occurred. Glaucoma and Cataracts Nasal and inhaled corticosteroids may result in the development of glaucoma and/or cataracts. Therefore, close monitoring is warranted in patients with a change in vision or with a history of increased intraocular pressure, glaucoma and/or cataracts. Immunosuppression Persons who are using drugs that suppress the immune system are more susceptible to infections than healthy individuals. Chickenpox and measles, for example, can have a more serious or even fatal course in susceptible children or adults using corticosteroids. In children or adults who have not had these diseases or have not been properly immunized, particular care should be taken to avoid exposure. How the dose, route, and duration of corticosteroid administration affect the risk of developing a disseminated infection is not known. The contribution of the underlying disease and/or prior corticosteroid treatment to the risk is also not known. If exposed to chickenpox, prophylaxis with varicella zoster immune globulin (VZIG) may be indicated. If exposed to measles, prophylaxis with pooled intramuscular immunoglobulin (IG) may be indicated. (See the respective package inserts for complete VZIG and IG prescribing information.) If chickenpox develops, treatment with antiviral agents may be considered. Corticosteroids should be used with caution, if at all, in patients with active or quiescent tuberculosis infections of the respiratory tract; untreated local or systemic fungal or bacterial infections; systemic viral or parasitic infections, or ocular herpes simplex because of the potential for worsening of these infections. Hypothalamic-Pituitary-Adrenal Axis Effects Hypercorticism and Adrenal Suppression When intranasal steroids are used at higher than recommended dosages or in susceptible individuals at recommended dosages, systemic corticosteroid effects such as hypercorticism and adrenal suppression may appear. If such changes occur, the dosage of NASACORT AQ Nasal Spray should be discontinued slowly, consistent with accepted procedures for discontinuing oral corticosteroid therapy. The replacement of a systemic corticosteroid with a topical corticosteroid can be accompanied by signs of adrenal insufficiency. In addition, some patients may experience symptoms of corticosteroid withdrawal, e.g., joint and/or muscular pain, lassitude, and depression. Patients previously treated for prolonged periods with systemic corticosteroids and transferred to topical corticosteroids should be carefully monitored for acute adrenal insufficiency in response to stress. In those patients who have asthma or other clinical conditions requiring long-term systemic corticosteroid treatment, rapid decreases in systemic corticosteroid dosages may cause a severe exacerbation of their symptoms. Effect on Growth Corticosteroids, including NASACORT AQ Nasal Spray, may cause a reduction in growth velocity when administered to pediatric patients. Monitor the growth routinely of pediatric patients receiving NASACORT AQ Nasal Spray. To minimize the systemic effects of intranasal corticosteroids, including NASACORT AQ Nasal Spray, titrate each patient's dose to the lowest dosage that effectively controls his/her symptoms [see Use in Specific Populations]. Patient Counseling Information See FDA-approved patient labeling (PATIENT INFORMATION and Instructions for Use). Local Nasal Effects Patients should be informed that treatment with NASACORT AQ Nasal Spray may lead to adverse reactions, which include epistaxis and nasal ulceration. Candida infection may also occur with treatment with NASACORT AQ Nasal Spray. In addition, nasal corticosteroids are associated with nasal septal perforation and impaired wound healing. Patients who have experienced recent nasal ulcers, nasal surgery, or nasal trauma should not use NASACORT AQ Nasal Spray until healing has occurred [see WARNINGS AND PRECAUTIONS]. Cataracts and Glaucoma Patients should be informed that glaucoma and cataracts are associated with nasal and inhaled corticosteroid use. Patients should inform his/her heath care provider if a change in vision is noted while using NASACORT AQ Nasal Spray [see WARNINGS AND PRECAUTIONS]. Immunosuppression Patients who are on immunosuppressant doses of corticosteroids should be warned to avoid exposure to chickenpox or measles and, if exposed, to consult their physician without delay. Patients should be informed of potential worsening of existing tuberculosis, fungal, bacterial, viral or parasitic infections, or ocular herpes simplex [see WARNINGS AND PRECAUTIONS]. Effect on Growth Parents should be advised that NASACORT AQ Nasal Spray may slow growth in children. A child taking NASACORT AQ Nasal Spray should have his/her growth checked regularly [see WARNINGS AND PRECAUTIONS and Pediatric Use]. Use Daily for Best Effect Patients should use NASACORT AQ Nasal Spray on a regular once-daily basis for optimal effect. It is also important to shake the bottle well before each use. Do not blow your nose for 15 minutes after using the spray. NASACORT AQ Nasal Spray, like other corticosteroids, does not have an immediate effect on rhinitis symptoms. Although improvement in some patient symptoms may be seen within the first day of treatment, maximum benefit may not be reached for up to one week. The patient should not increase the prescribed dosage but should contact the physician if symptoms do not improve or if the condition worsens. Keep Spray Out of Eyes Patients should be informed to avoid spraying NASACORT AQ Nasal Spray in their eyes. IMPORTANT: Please read these instructions carefully before using your NASACORT®AQ Nasal Spray Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment of Fertility In a two-year study in rats, triamcinolone acetonide caused no treatment-related carcinogenicity at oral doses up to 1.0 mcg/kg (less than the maximum recommended daily intranasal dose in adults and children on a mcg/m² basis, respectively). In a two-year study in mice, triamcinolone acetonide caused no treatment-related carcinogenicity at oral doses up to 3.0 mcg/kg (less than the maximum recommended daily intranasal dose in adults and children on a mcg/m² basis, respectively). No evidence of mutagenicity was detected from in vitro tests (a reverse mutation test in Salmonella bacteria and a forward mutation test in Chinese hamster ovary cells) conducted with triamcinolone acetonide. In male and female rats, triamcinolone acetonide caused no change in pregnancy rate at oral doses up to 15.0 mcg/kg (less than the maximum recommended daily intranasal dose in adults on a mcg/m² basis). Triamcinolone acetonide caused increased fetal resorptions and stillbirths and decreases in pup weight and survival at doses of 5.0 mcg/kg and above (less than the maximum recommended daily intranasal dose in adults on a mcg/m² basis). At 1.0 mcg/kg (less than the maximum recommended daily intranasal dose in adults on a mcg/m² basis), it did not induce the above mentioned effects. Use In Specific Populations Pregnancy Teratogenic Effects - Pregnancy Category C There are no adequate and well-controlled studies of NASACORT AQ Nasal Spray in pregnant women. Triamcinolone acetonide was teratogenic in rats, rabbits, and monkeys. NASACORT AQ Nasal Spray, like other corticosteroids, should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Since their introduction, experience with oral corticosteroids in pharmacologic as opposed to physiologic doses suggests that rodents are more prone to teratogenic effects from corticosteroids than humans. In addition, because there is a natural increase in glucocorticoid production during pregnancy, most women will require a lower exogenous corticosteroid dose and many will not need corticosteroid treatment during pregnancy. In reproduction studies in rats and rabbits, triamcinolone acetonide administered by inhalation produced cleft palate and/or internal hydrocephaly and axial skeletal defects at exposures less than and 2 times, respectively, the maximum recommended daily intranasal dose in adults on a mcg/m² basis. In a monkey reproduction study, triamcinolone acetonide administered by inhalation produced cranial malformations at an exposure approximately 37 times the maximum recommended daily intranasal dose in adults on a mcg/m² basis. Nursing Mothers It is not known whether triamcinolone acetonide is excreted in human milk. Because other corticosteroids are excreted in human milk, caution should be exercised when NASACORT AQ Nasal Spray is administered to nursing women. Pediatric Use The safety and effectiveness of NASACORT AQ Nasal Spray has been evaluated in 464 children 2 to 5 years of age, 518 children 6 to 12 years of age, and 176 adolescents 12 to 17 years of age [see Clinical Studies]. The safety and effectiveness of NASACORT AQ Nasal Spray in children below 2 years of age have not been established. Controlled clinical studies have shown that intranasal corticosteroids may cause a reduction in growth velocity in pediatric patients. This effect has been observed in the absence of laboratory evidence of HPA axis suppression, suggesting that growth velocity is a more sensitive indicator of systemic corticosteroid exposure in pediatric patients than some commonly used tests of HPA axis function. The long-term effects of reduction in growth velocity associated with intranasal corticosteroids, including the impact on final adult height are unknown. The potential for “catchup” growth following discontinuation of treatment with intranasal corticosteroids has not been adequately studied. The growth of pediatric patients receiving intranasal corticosteroids, including NASACORT AQ Nasal Spray, should be monitored routinely (e.g., via stadiometry). The potential growth effects of treatment should be weighed against the clinical benefits obtained and the risks/benefits of treatment alternatives. To minimize the systemic effects of intranasal corticosteroids, including NASACORT AQ Nasal Spray, each patient's dose should be titrated to the lowest dosage that effectively controls his/her symptoms. The effect of NASACORT AQ Nasal Spray on growth velocity in children was assessed in a 12 month randomized, placebo controlled study conducted in 299 prepubescent children age 3 to 9 years (173 males, 126 females) with perennial allergic rhinitis. Treatment groups were NASACORT AQ 110 mcg once daily and placebo. Growth velocity was estimated for each patient using the slope of the linear regression of height over time using observed data in the intent to treat population who had at least 3 height measurements after randomization. Growth velocities were significantly lower in the NASACORT AQ group compared to placebo, with a mean growth velocity of 6.09 cm/year in the placebo group and 5.65 cm/year in the NASACORT AQ treated group (difference from placebo -0.45 cm/year; 95% CI: -0.78, -0.11). Geriatric Use Clinical studies of NASACORT AQ did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

WARNINGS Particular care is needed in patients who are transferred from systemically active corticosteroids to Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol because deaths due to adrenal insufficiency have occurred in asthmatic patients during and after transfer from systemic corticosteroids to aerosolized steroids in recommended doses. After withdrawal from systemic corticosteroids, a number of months is usually required for recovery of hypothalamic-pituitary-adrenal (HPA) function. For some patients who have received large doses of oral steroids for long periods of time before therapy with Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol is initiated, recovery may be delayed for one year or longer. During this period of HPA suppression, patients may exhibit signs and symptoms of adrenal insufficiency when exposed to trauma, surgery, or infections, particularly gastroenteritis or other conditions with acute electrolyte loss. Although Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol may provide control of asthmatic symptoms during these episodes, in recommended doses it supplies only normal physiological amounts of corticosteroid systemically and does NOT provide the increased systemic steroid which is necessary for coping with these emergencies. During periods of stress or a severe asthmatic attack, patients who have been recently withdrawn from systemic corticosteroids should be instructed to resume systemic steroids (in large doses) immediately and to contact their physician for further instruction. These patients should also be instructed to carry a warning card indicating that they may need supplementary systemic steroids during periods of stress or a severe asthma attack. Localized infections with Candida albicans have occurred infrequently in the mouth and pharynx. These areas should be examined by the treating physician at each patient visit. The percentage of positive mouth and throat cultures for Candida albicans did not change during a year of continuous therapy. The incidence of clinically apparent infection is low (2.5%). These infections may disappear spontaneously or may require treatment with appropriate antifungal therapy or discontinuance of treatment with Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol. Children who are on immunosuppressant drugs are more susceptible to infections than healthy children. Chickenpox and measles, for example, can have a more serious or even fatal course in children on immunosuppressant doses of corticosteroids. In such children, or in adults who have not had these diseases, particular care should be taken to avoid exposure. If exposed, therapy with varicella zoster immune globulin (VZIG) or pooled intravenous immunoglobulin (IVIG), as appropriate, may be indicated. If chickenpox develops, treatment with antiviral agents may be considered. Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol is not to be regarded as a bronchodilator and is not indicated for rapid relief of bronchospasm. As with other inhaled asthma medications, bronchospasm may occur with an immediate increase in wheezing following dosing. If bronchospasm occurs following use of Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol, it should be treated immediately with a fast-acting inhaled bronchodilator. Treatment with Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol should be discontinued and alternative treatment should be instituted. Patients should be instructed to contact their physician immediately when episodes of asthma which are not responsive to bronchodilators occur during the course of treatment with Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol. During such episodes, patients may require therapy with systemic corticosteroids. The use of Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol with systemic prednisone, dosed either daily or on alternate days, could increase the likelihood of HPA suppression compared to a therapeutic dose of either one alone. Therefore, Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol should be used with caution in patients already receiving prednisone treatment for any disease. Transfer of patients from systemic steroid therapy to Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol may unmask allergic conditions previously suppressed by the systemic steroid therapy, e.g., rhinitis, conjunctivitis, and eczema. PRECAUTIONS Orally inhaled corticosteroids may cause a reduction in growth velocity when administered to pediatric patients (see PRECAUTIONS, Pediatric Use). Because of the possibility of systemic absorption of inhaled corticosteroids, patients treated with these drugs should be observed carefully for any evidence of systemic corticosteroid effects including suppression of growth in children. Particular care should be taken in observing patients postoperatively or during periods of stress for evidence of a decrease in adrenal function. During withdrawal from oral steroids, some patients may experience symptoms of systemically active steroid withdrawal, e.g., joint and/or muscular pain, lassitude, and depression, despite maintenance or even improvement of respiratory function. (See DOSAGE AND ADMINISTRATION.) Although steroid withdrawal effects are usually transient and not severe, severe and even fatal exacerbation of asthma can occur if the previous daily oral corticosteroid requirement had significantly exceeded 10 mg/day of prednisone or equivalent. In responsive patients, inhaled corticosteroids will often permit control of asthmatic symptoms with less suppression of HPA function than therapeutically equivalent oral doses of prednisone. Since triamcinolone acetonide is absorbed into the circulation and can be systemically active, the beneficial effects of Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol in minimizing or preventing HPA dysfunction may be expected only when recommended dosages are not exceeded. Suppression of HPA function has been reported in volunteers who received 4000 mcg daily of triamcinolone acetonide by oral inhalation. In addition, suppression of HPA function has been reported in some patients who have received recommended doses for as little as 6 to 12 weeks. Since the response of HPA function to inhaled corticosteroids is highly individualized, the physician should consider this information when treating patients. When used at excessive doses or at recommended doses in a small number of susceptible individuals, systemic corticosteroid effects such as hypercorticoidism and adrenal suppression may appear. If such changes occur, Azmacort (triamcinolone acetonide (inhalation aerosol)) ® Inhalation Aerosol should be discontinued slowly, consistent with accepted procedures for reducing systemic steroid therapy and for management of asthma symptoms. Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol should be used with caution, if at all, in patients with active or quiescent tuberculosis infection of the respiratory tract; untreated systemic fungal, bacterial, parasitic, or viral infections; or ocular herpes simplex. The long-term local and systemic effects of Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol in human subjects are still not fully known. While there has been no clinical evidence of adverse experiences, the effects resulting from chronic use of Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol on developmental or immunologic processes in the mouth, pharynx, trachea, and lung are unknown. Information for Patients: Patients being treated with Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol should receive the following information and instructions. This information is intended to aid them in the safe and effective use of this medication. It is not a complete disclosure of all possible adverse or intended effects. Patients should use Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol at regular intervals as directed. Results of clinical trials indicate that significant improvement in asthma may occur by 1 week, but maximum benefit may not be achieved for 2 weeks or more. The patient should not increase the prescribed dosage but should contact the physician if symptoms do not improve or if the condition worsens. In clinical studies and post-marketing experience with Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol, local infections of the oropharynx with Candida albicans have occurred. When such an infection develops, it should be treated with appropriate local or systemic (i.e., oral antifungal) therapy while remaining on treatment with Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol. However, at times therapy with Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol may need to be interrupted. Patients should be instructed to track their use of Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol and to dispose of the canister after 240 actuations since reliable dose delivery cannot be assured after 240 doses. Patients who are on immunosuppressant doses of corticosteroids should be warned to avoid exposure to chickenpox or measles and, if exposed, to obtain medical advice. Carcinogenesis, Mutagenesis, Impairment of Fertility: No evidence of treatment-related carcinogenicity was demonstrated after two years of once daily gavage of triamcinolone acetonide at doses of 0.05, 0.2, and 1.0 mcg/kg (approximately 0.02, 0.07, and 0.4% of the maximum recommended human daily inhalation dose on a mcg/m2 basis) in the rat and 0.1, 0.6, and 3.0 mcg/kg (approximately 0.02, 0.1, and 0.6% of the maximum recommended human daily inhalation dose on a mcg/m2 basis) in a mouse. Mutagenesis studies with triamcinolone acetonide have not been carried out. No evidence of impaired fertility was manifested when oral doses of up to 15.0 mcg/kg (8% of the maximum recommended human daily inhalation dose on a mcg/m2 basis) were administered to female and male rats. However, triamcinolone acetonide at oral doses of 8 mcg/kg (approximately 4% of the maximum recommended human daily inhalation dose on a mcg/m2 basis) caused dystocia and prolonged delivery and at oral doses of 5.0 mcg/kg (approximately 2.5% of the maximum recommended human daily inhalation dose on a mcg/m2 basis) and above caused increases in fetal resorptions and stillbirths and decreases in pup body weight and survival. At a lower dose of 1.0 mcg/kg (approximately 0.5% of the maximum recommended human daily inhalation dose on a mcg/m2 basis) it did not induce the above mentioned effects. Pregnancy: Pregnancy Category C. Triamcinolone acetonide has been shown to be teratogenic at inhalational doses of 20, 40, and 80 mcg/kg in rats (approximately 0.1, 0.2, and 0.4 times the maximum recommended human daily inhalation dose on a mcg/m2 basis, respectively), in rabbits at the same doses (approximately 0.2, 0.4, and 0.8 times the maximum recommended human daily inhalation dose on a mcg/m2 basis, respectively) and in monkeys, at an inhalational dose of 500 mcg/kg (approximately 5 times the maximum recommended human daily inhalation dose on a mcg/m2 basis). Dose related teratogenic effects in rats and rabbits included cleft palate and/or internal hydrocephaly and axial skeletal defects whereas the teratogenic effects observed in the monkey were CNS and/or cranial malformations. There are no adequate and well controlled studies in pregnant women. Triamcinolone acetonide should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Experience with oral glucocorticoids since their introduction in pharmacologic as opposed to physiologic doses suggests that rodents are more prone to teratogenic effects from glucocorticoids than humans. In addition, because there is a natural increase in glucocorticoid production during pregnancy, most women will require a lower exogenous steroid dose and many will not need glucocorticoid treatment during pregnancy. Nonteratogenic Effects: Hypoadrenalism may occur in infants born of mothers receiving corticosteroids during pregnancy. Such infants should be carefully observed. Nursing Mothers: It is not known whether triamcinolone acetonide is excreted in human milk. Because other corticosteroids are excreted in human milk, caution should be exercised when Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol is administered to nursing women. Pediatric Use: Safety and effectiveness have not been established in pediatric patients below the age of 6. Controlled clinical studies have shown that orally inhaled corticosteroids may cause a reduction in growth velocity in pediatric patients. In these studies, the mean reduction in growth velocity was approximately one centimeter (cm) per year (range 0.3 to 1.8 cm per year; 0.12 to 0.71 inches) and appears to depend upon dose and duration of exposure. [The specific growth effects of Azmacort (triamcinolone acetonide (inhalation aerosol)) have also been studied in a controlled clinical trial (see data below)]. This effect was observed in the absence of laboratory evidence of hypothalamic-pituitary-adrenal (HPA) axis suppression, suggesting that growth velocity is a more sensitive indicator of systemic corticosteroid exposure in pediatric patients than some commonly used tests of HPA axis function. To assess if Azmacort (triamcinolone acetonide (inhalation aerosol)) has an effect on growth, a one-year, randomized, open-label study of pre-pubescent boys and girls ages 6-11 with moderate to severe asthma was conducted. Children with moderate asthma were randomized to a nonsteroidal treatment or to Azmacort (triamcinolone acetonide (inhalation aerosol)) , children with severe asthma to Azmacort (triamcinolone acetonide (inhalation aerosol)) plus prednisone or just prednisone alone. A sex and age matched group of healthy non-asthmatic children was also included. The average daily dose of Azmacort (triamcinolone acetonide (inhalation aerosol)) was 400 mcg (range 75 to 1600 mcg/day, dose adjustments were permitted). Non-asthmatic children (mean 8.2 years) grew 5.93 cm/year (n=96). In the moderate asthma groups, the Azmacort (triamcinolone acetonide (inhalation aerosol)) children (mean 8.2 years) grew 5.34 cm/year (n=101) and the nonsteroidal children (mean 8.5 years) grew 6.13 cm/year (n=95). In the severe groups, the Azmacort (triamcinolone acetonide (inhalation aerosol)) plus prednisone children (mean 8.2 years) grew 5.46 cm/year (n=33) and the prednisone only children (mean 8.0 years) grew 5.59 cm/year (n=31). Due to low enrollment in the severe patient groups, there was insufficient power to interpret the statistical analyses on these groups. The long-term effects of this reduction in growth velocity associated with orally inhaled corticosteroids, including the impact on final adult height, are unknown. The potential for "catch up" growth following discontinuation of treatment with orally inhaled corticosteroids has not been adequately studied. The growth of children and adolescents receiving orally inhaled corticosteroids, including Azmacort (triamcinolone acetonide (inhalation aerosol)) , should be monitored routinely (e.g. via stadiometry). The potential growth effects of prolonged treatment should be weighed against the clinical benefits obtained and the risk associated with alternative therapies. To minimize the systemic effects of orally inhaled corticosteroids, including Azmacort (triamcinolone acetonide (inhalation aerosol)) , each patient should be titrated to the lowest dose that effectively controls his/her symptoms. Geriatric Use: Clinical studies of Azmacort (triamcinolone acetonide (inhalation aerosol)) Inhalation Aerosol did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.