When is 2 sprays in each nostril twice daily of Flonase (fluticasone) indicated?

Fluticasone Nasal Spray (Flonase) Dosing: 2 Sprays in Each Nostril Twice Daily

Fluticasone propionate nasal spray at a dosage of 2 sprays in each nostril twice daily (total 200 mcg twice daily) is indicated for adults with allergic rhinitis who require higher dosing for symptom control, particularly those with moderate to severe symptoms. 1

Approved Indications for Fluticasone Propionate (Flonase) 2 Sprays Twice Daily

• The FDA-approved dosing for adults with allergic rhinitis allows for 2 sprays in each nostril once daily (200 mcg total) OR the same total daily dosage divided into 100 mcg given twice daily (1 spray in each nostril twice daily) 1
• For adults with more severe or inadequately controlled symptoms, the maximum recommended dosage is 2 sprays in each nostril twice daily (400 mcg total daily) 1
• This higher dosing regimen is typically used for initial treatment of moderate to severe allergic rhinitis symptoms, with the expectation of reducing to maintenance dosing once symptoms are controlled 1, 2

Patient-Specific Considerations for Higher Dosing

• Higher dosing (2 sprays in each nostril twice daily) may be particularly beneficial for:
  • Patients with severe nasal congestion that has not responded to standard dosing 2, 3
  • Cases where once-daily dosing provides inadequate 24-hour symptom control 1, 4
  • Patients with both allergic rhinitis and nasal polyps who require more intensive therapy 3

Dosing Differences by Age Group

• For children 4-11 years: The recommended starting dose is 1 spray in each nostril once daily (100 mcg total); may increase to 2 sprays in each nostril once daily (200 mcg total) if inadequate response 1, 5
• For adolescents (≥12 years) and adults: Starting dose is 2 sprays in each nostril once daily (200 mcg total), with flexibility to divide into twice-daily dosing 2, 1
• Fluticasone propionate is not recommended for children under 4 years of age 1, 3

Efficacy Considerations

• Clinical studies have shown that fluticasone propionate is effective for both seasonal and perennial allergic rhinitis 4, 6
• Once-daily dosing (200 mcg) has been shown to be as effective as twice-daily beclomethasone dipropionate for seasonal allergic rhinitis in adults 6
• For some patients with more severe symptoms, twice-daily administration may provide better symptom control throughout the 24-hour period 1, 7

Safety Considerations

• Common side effects include headache, pharyngitis, epistaxis, nasal burning/irritation, nausea, and cough 2, 8
• The twice-daily regimen may increase the risk of local side effects such as epistaxis compared to once-daily dosing 8
• Contraindicated in patients with hypersensitivity to fluticasone or its components 2, 8

Practical Recommendations

• After initial treatment with higher doses, patients should be stepped down to the lowest effective dose for maintenance therapy (typically 1 spray in each nostril once daily) 1
• Proper administration technique is crucial to minimize side effects and maximize efficacy 3
• Regular use provides better symptom control than as-needed use, though some patients with seasonal allergic rhinitis may achieve adequate control with as-needed use 1

Alternative Options

• If fluticasone propionate is not tolerated or effective, other intranasal corticosteroids like mometasone furoate or triamcinolone acetonide may be considered 2, 3
• For patients who cannot tolerate intranasal corticosteroids, intranasal antihistamines like azelastine may be an alternative, though they may cause sedation 2, 9