Is Flonase (fluticasone) safe to use during the second trimester of pregnancy?

Safety of Flonase (Fluticasone) During Second Trimester of Pregnancy

Fluticasone nasal spray (Flonase) is safe to use during the second trimester of pregnancy and can be recommended for treating allergic rhinitis symptoms with minimal risk to the fetus.

Evidence for Safety in Pregnancy

Intranasal corticosteroids have a well-established safety profile during pregnancy, particularly after the first trimester. The evidence supports their use when clinically indicated:

• Clinical and epidemiologic studies show that intranasal corticosteroids have a favorable safety profile during pregnancy 1
• Pharmacologic studies demonstrate much lower systemic exposure with intranasal corticosteroids compared to orally inhaled corticosteroids 1
• A meta-analysis concluded that inhaled corticosteroids during pregnancy do not increase risks of major malformations, preterm delivery, low birth weight, or pregnancy-induced hypertension 1

Specific Evidence for Fluticasone

Fluticasone propionate (Flonase) specifically:

• Is FDA-approved for allergic rhinitis in patients ≥4 years old 1
• Has limited systemic absorption due to its topical application
• No evidence of harm has been reported when used in second or third trimesters 1
• Recent research indicates no significant association with congenital organ malformations has been linked to intranasal use of fluticasone propionate or fluticasone furoate 2

Treatment Algorithm for Allergic Rhinitis in Pregnancy

1. First-line options (safest):

   • Intranasal sodium cromolyn (Pregnancy Category B) 1
   • Intranasal corticosteroids including fluticasone 1

2. Second-line options:

   • First-generation antihistamines (e.g., chlorpheniramine) 3
   • Second-generation antihistamines (with caution) 1

3. Third-line/avoid if possible:

   • Oral decongestants (should be avoided, especially in first trimester) 1
   • Topical decongestants (short-term use only) 1

Important Clinical Considerations

• Intranasal corticosteroids like fluticasone have minimal systemic absorption, reducing potential fetal exposure 1
• The benefits of treating moderate to severe allergic rhinitis often outweigh the theoretical risks, as untreated symptoms can affect maternal quality of life and potentially sleep quality
• Standard dosing should be used: for adults, 2 sprays per nostril daily 1

Potential Concerns and Precautions

• While most evidence supports safety, individual patient factors should be considered
• Common side effects include headache, pharyngitis, epistaxis, nasal burning or irritation 1
• Avoid exceeding recommended doses to minimize systemic absorption
• If symptoms are mild, non-pharmacological approaches (saline nasal irrigation, allergen avoidance) can be tried first

In conclusion, based on the available evidence, fluticasone nasal spray is considered safe during the second trimester of pregnancy when used as directed, with no evidence of increased risk for congenital malformations or other adverse pregnancy outcomes.