What happens if someone inhales fluticasone (fluticasone furoate) multiple times a day?

Potential Consequences of Multiple Daily Fluticasone Furoate Inhalations

Inhaling fluticasone furoate multiple times per day beyond the recommended dosage can lead to increased risk of systemic side effects including adrenal suppression, with minimal additional therapeutic benefit.

Recommended Dosing vs. Excessive Use

Fluticasone furoate is designed for once-daily dosing, with specific maximum recommended doses:

• For asthma management:

  • Children 4-11 years: 50-100 mcg once daily 1
  • Adolescents/adults ≥12 years: 100-200 mcg once daily 1

• For nasal symptoms:

  • Children 4-11 years: 1 spray per nostril once daily (50 mcg/spray) 1
  • Adolescents/adults ≥12 years: 2 sprays per nostril once daily 1

Systemic Side Effects of Excessive Use

When fluticasone furoate is used multiple times daily (exceeding recommendations):

1. Adrenal Suppression Risk:

   • Significant suppression of overnight urinary cortisol/creatinine occurs at higher doses 2
   • Fluticasone furoate's AUC50 (concentration causing 50% of maximum cortisol suppression) is 1,556-1,686 pg·h/mL 3
   • Multiple daily doses would increase systemic exposure beyond this threshold

2. HPA Axis Effects:

   • While standard doses generally don't cause clinically significant HPA axis effects 4, multiple daily doses increase this risk
   • Cortisol suppression becomes significant with higher systemic exposure 3

3. Local Side Effects Increase:

   • Higher risk of oropharyngeal candidiasis (thrush) 5
   • Increased likelihood of dysphonia (voice changes) 1
   • Greater chance of pharyngeal irritation 4

4. No Additional Therapeutic Benefit:

   • Studies show once-daily dosing of fluticasone furoate is as effective as twice-daily dosing of the same total dose 6
   • FF 200 μg once daily was non-inferior to FF 100 μg twice daily in improving pre-dose FEV1 6

Special Considerations

• Children and Growth: Higher doses may potentially affect growth in pediatric patients 1
• Bone Health: Fluticasone might lead to bone loss at total daily doses higher than 750 mcg 4
• Risk vs. Benefit: For conditions like eosinophilic esophagitis, higher doses may be prescribed (up to 880-1760 mcg/day), but these are swallowed rather than inhaled and have different risk profiles 4

Proper Administration to Minimize Risks

To reduce risks when using prescribed doses:

• Use a spacer or valved holding chamber with metered dose inhalers 1
• Rinse mouth after inhalation to prevent local side effects 1, 5
• For nasal spray, direct spray away from nasal septum 1

Clinical Management of Excessive Use

If a patient is using multiple daily doses:

1. Reassess symptom control and diagnosis
2. Consider alternative or additional controller medications rather than increasing fluticasone dose 1
3. Monitor for signs of adrenal suppression (fatigue, weakness, nausea)
4. In children, monitor growth regularly 1
5. Consider checking morning cortisol levels if systemic effects are suspected

Multiple daily inhalations of fluticasone furoate should be avoided as they increase systemic exposure without providing additional clinical benefit while significantly increasing the risk of both local and systemic adverse effects.