Fluticasone Dosing for Allergic Rhinitis
For adults and adolescents ≥12 years with allergic rhinitis, start with fluticasone propionate 200 mcg once daily (2 sprays per nostril), which can alternatively be divided as 100 mcg twice daily (1 spray per nostril twice daily). 1
Adult and Adolescent Dosing (≥12 years)
- Initial dose: 200 mcg once daily (2 sprays of 50 mcg per nostril once daily in the morning) 1
- Alternative regimen: 100 mcg twice daily (1 spray per nostril twice daily) is equally effective 1, 2
- After 4-7 days of symptom control, reduce to maintenance dose of 100 mcg once daily (1 spray per nostril) 1
- Maximum dose: Do not exceed 200 mcg/day total (2 sprays per nostril); exceeding this provides no additional benefit 1
- For severe nasal congestion unresponsive to standard dosing, consider 200 mcg twice daily temporarily, then reduce once controlled 3
Clinical trials showed no significant difference between once-daily versus twice-daily administration of the same total daily dose 1, and fluticasone 200 mcg once daily equals the efficacy of beclomethasone 168 mcg twice daily 2, 4.
Pediatric Dosing (Ages 4-11 years)
- Start with 100 mcg once daily (1 spray per nostril) 1, 5
- Reserve 200 mcg daily (2 sprays per nostril once daily OR 1 spray per nostril twice daily) only for children inadequately responding to 100 mcg 1
- Once adequate control achieved, decrease back to 100 mcg daily 1
- Maximum: 200 mcg/day total 1
Studies in children ages 4-11 demonstrated that 100 mcg once daily is as effective as 200 mcg once daily, making the lower dose preferable 5.
Onset and Maintenance Considerations
- Symptom improvement begins as early as 12 hours after first dose 1
- Maximum therapeutic effect requires several days to weeks of regular use 3, 6, 1
- Regular scheduled use is superior to as-needed use for optimal symptom control 3, 6
- As-needed dosing (not exceeding 200 mcg daily) may be effective in some patients ≥12 years with seasonal allergic rhinitis, though scheduled use provides better control 1
Important Clinical Caveats
- Proper administration technique is critical: Use contralateral hand technique (right hand for left nostril), keep head upright, breathe in gently during spray, and avoid closing opposite nostril 3, 6
- The contralateral spray technique reduces epistaxis risk by 4-fold compared to ipsilateral technique 3
- Common side effects include headache, pharyngitis, epistaxis, and nasal irritation 3, 6, 1
- Contraindicated in patients with hypersensitivity to fluticasone or its components 3, 6
- No clinically significant hypothalamic-pituitary-adrenal axis suppression occurs at recommended doses in children or adults 3, 5, 7
Combination Therapy for Moderate-to-Severe Disease
For patients ≥12 years with moderate-to-severe seasonal allergic rhinitis not adequately controlled on fluticasone alone, consider adding intranasal azelastine (fluticasone 200 mcg + azelastine 548 mcg as combination spray provides clinically meaningful additional symptom reduction) 8.