What is the recommended dosage and treatment regimen for Fluticasone (fluticasone) nasal spray in allergic rhinitis?

Fluticasone Nasal Spray for Allergic Rhinitis

Recommended Dosage

For adults and adolescents ≥12 years, start with 2 sprays (50 mcg each) per nostril once daily (200 mcg total daily dose), and for children ages 4-11 years, use 1 spray per nostril once daily (100 mcg total daily dose). 1, 2

Adult Dosing (≥12 years)

• Initial dose: 2 sprays per nostril once daily (200 mcg/day) 1, 2
• Alternative regimen: 100 mcg twice daily (1 spray per nostril at 8 AM and 8 PM) is equally effective 1
• Maintenance dose: After the first few days, many patients can reduce to 1 spray per nostril once daily (100 mcg/day) 1
• As-needed use: For seasonal allergic rhinitis in patients ≥12 years, 200 mcg once daily used only on symptomatic days (not exceeding 75% of days) is effective, though scheduled regular use provides greater symptom control 1

Pediatric Dosing (4-11 years)

• Initial dose: 1 spray per nostril once daily (100 mcg/day) 1, 2
• If inadequate response: May increase to 2 sprays per nostril once daily (200 mcg/day) 1
• Once controlled: Decrease back to 1 spray per nostril daily 1
• Maximum dose: Do not exceed 2 sprays per nostril daily (200 mcg/day) 1
• Not approved: Fluticasone propionate is not FDA-approved for children under 4 years 1, 2

Treatment Regimen and Timing

Onset and Duration

• Initial effect: Symptom reduction begins as early as 12 hours after the first dose 1, 3
• Maximum efficacy: Reached within days to weeks of regular use 3, 4
• Regular use required: Daily scheduled administration is more effective than as-needed use for maintaining optimal symptom control 3, 1

Once Daily vs. Twice Daily Dosing

• Equivalent efficacy: 200 mcg once daily is as effective as 100 mcg twice daily 1, 5, 6
• Once daily advantage: Better compliance due to convenience, with no difference in safety or efficacy 6, 7
• Timing flexibility: The 200 mcg total daily dose can be given as a single morning dose or split into twice-daily administration based on patient preference 1

Proper Administration Technique

Correct technique is critical to minimize side effects and maximize efficacy. 3, 4

• Prime the bottle before first use 3
• Shake the bottle prior to each use 3
• Blow nose before administration 3
• Keep head upright during spraying 3
• Use contralateral hand technique: Hold the spray in the opposite hand relative to the nostril being treated (reduces epistaxis risk by 4-fold) 4
• Breathe in gently during spraying 3
• Do not close the opposite nostril during administration 3
• If using nasal saline irrigations, perform them before the steroid spray 4

Common Side Effects

The most frequent adverse effects include 2, 3, 4:

• Headache
• Pharyngitis
• Epistaxis (nosebleeds) - minimized with proper contralateral technique 4
• Nasal burning or irritation
• Nausea or vomiting
• Cough

Important: Local side effects like nasal septal perforation are rare and preventable with correct administration technique 4

Safety Considerations

Growth and HPA Axis

• No growth suppression: Studies with fluticasone propionate at recommended doses show no effect on growth in children compared to placebo 4
• No HPA axis suppression: No clinically relevant effects on the hypothalamic-pituitary-adrenal axis in children or adults at recommended doses 4, 8

Contraindications

• Hypersensitivity to fluticasone propionate or any component of the formulation 2, 3

Alternative Formulations

If fluticasone propionate is not suitable:

• Fluticasone furoate (Veramyst): Approved for children ≥2 years at 1-2 sprays per nostril daily (27.5 mcg per spray) 2
• Other intranasal corticosteroids: Mometasone furoate or triamcinolone acetonide may be considered 4
• Combination therapy: Azelastine plus fluticasone (Dymista) provides 137 mcg azelastine and 50 mcg fluticasone per spray, dosed as 1 spray per nostril twice daily for patients ≥12 years 9

Clinical Pearls

• Topical, not systemic effect: The efficacy of fluticasone nasal spray results from direct topical action on nasal tissues, not systemic absorption 10
• Superior to oral antihistamines: Intranasal corticosteroids are more effective than oral antihistamines for all nasal symptoms, particularly nasal congestion 4
• Patient education critical: Teaching proper technique using visual aids or demonstrations significantly improves competency and outcomes 4