What is the recommended dose and duration of fluticasone (Flonase) for pediatric patients?

Fluticasone Dosing and Duration for Pediatric Patients

For pediatric patients with allergic rhinitis, fluticasone nasal spray should be dosed at 1 spray per nostril daily (50 mcg/spray) for children 4-11 years and 2 sprays per nostril daily (100 mcg/spray) for children 12 years and older, with treatment duration guided by symptom control and minimized to the shortest effective period.

Age-Specific Dosing Recommendations

Nasal Fluticasone (Flonase) for Allergic Rhinitis:

• Ages 2-3 years: Not FDA approved
• Ages 4-11 years:
  • 1 spray per nostril once daily (50 mcg/spray, total 100 mcg/day) 1
  • If inadequate response, may increase to 2 sprays per nostril once daily (200 mcg/day) 2
• Ages ≥12 years and adults:
  • 2 sprays per nostril once daily (total 200 mcg/day) 1, 2
  • May be divided into 100 mcg twice daily 2
  • Once control is achieved, may reduce to 1 spray per nostril daily (100 mcg/day) for maintenance 2

Inhaled Fluticasone for Asthma:

• Ages <4 years: Not recommended (budesonide is the only FDA-approved ICS for this age group) 3
• Ages 4-11 years:
  • Low dose: 88-176 mcg/day via HFA/MDI 1
  • Medium dose: 176-352 mcg/day 1
  • High dose: >352 mcg/day 1
• Ages ≥12 years:
  • Low dose: 88-264 mcg/day 1
  • Medium dose: 264-440 mcg/day 1
  • High dose: >440 mcg/day 1

Duration of Treatment

The duration of fluticasone treatment should be guided by:

1. Symptom control: Continue until adequate symptom control is achieved, then consider step-down therapy 1
2. Minimum effective dose: Once control is achieved, the dose should be carefully titrated to the minimum dose required to maintain control 1
3. Seasonal considerations: For seasonal allergic rhinitis, treatment may be limited to the allergy season
4. Regular assessment: Efficacy should be assessed within 4-6 weeks of initiation 3

Administration Guidelines

• Nasal spray: Proper technique includes tilting head slightly forward and directing spray away from the nasal septum
• Inhaled (asthma):
  • Children <4 years generally require delivery through a face mask 1
  • Use spacer or valved holding chamber with MDIs 1
  • Rinse mouth after inhalation to prevent local side effects 1

Safety Considerations

• Growth concerns: At recommended doses (100-200 mcg/day), fluticasone has no clinically significant effect on growth velocity 4
• HPA axis: At standard doses, no significant effect on hypothalamic-pituitary-adrenal axis function 4, 5
• High doses: Daily doses >500 mcg for extended periods may affect growth rate, bone density, and adrenal function 4
• Common side effects:
  • Nasal: Epistaxis, headache, pharyngitis, nasal burning/irritation 1
  • Inhaled: Cough, dysphonia, oral thrush 1

Clinical Pearls

• The 100 mcg daily dose of fluticasone nasal spray has been shown to be as effective as 200 mcg daily in children as young as 4 years 5, 6
• For inhaled fluticasone in asthma, most children achieve control with 100-200 mcg/day, with minimal additional benefit from higher doses 4
• Morning plasma cortisol concentrations remain similar to placebo at recommended pediatric doses 5, 6, 7
• Patient/caregiver education on proper administration technique is essential for efficacy and minimizing side effects

Monitoring Recommendations

• Regular assessment of symptom control
• Growth monitoring in children on long-term therapy
• Consider morning plasma cortisol in children on high doses (>500 mcg/day) for extended periods
• Evaluate for local side effects (nasal irritation, oral thrush)

Remember that the goal of therapy is to use the lowest effective dose for the shortest duration needed to maintain symptom control while minimizing potential side effects.