What is the recommended dosage of fluticasone (Flonase) nasal spray?

Fluticasone Nasal Spray Dosage

For adults and adolescents ≥12 years, start with 2 sprays 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

Age-Specific Dosing Recommendations

Adults and Adolescents (≥12 years)

• The FDA-approved starting dose is 2 sprays (50 mcg each) per nostril once daily for a total of 200 mcg daily 1
• This same 200 mcg dose can alternatively be divided into 100 mcg twice daily (e.g., 8 a.m. and 8 p.m.), which is equally effective 1
• After the first few days, many patients can reduce to a maintenance dose of 1 spray per nostril once daily (100 mcg total) 1
• The maximum daily dose should not exceed 2 sprays per nostril (200 mcg/day) 1

Children (4-11 years)

• Start with 1 spray per nostril once daily (100 mcg total daily dose) 1
• If inadequate response occurs, the dose may be increased to 2 sprays per nostril once daily (200 mcg) 1
• Once adequate control is achieved, decrease back to 1 spray per nostril daily 1
• Research confirms that 100 mcg once daily is as effective as 200 mcg once daily in children as young as 4 years 2

Young Children (<4 years)

• Fluticasone propionate nasal spray is not FDA-approved for children under 4 years of age 1
• For children ages 2-3 years requiring intranasal steroid therapy, fluticasone furoate (Veramyst) is an alternative formulation approved for ages ≥2 years at 1-2 sprays per nostril daily 3

Timing and Duration Considerations

• Onset of action is delayed approximately 12 hours, with maximal efficacy reached over days to weeks 4
• Regular scheduled use is more effective than as-needed administration for maintaining optimal symptom control 4
• For seasonal allergic rhinitis, initiation before symptom onset and continuation throughout the allergen exposure period provides the best results 5
• Intranasal corticosteroids do not cause rhinitis medicamentosa and are safe for long-term daily use, unlike topical decongestants which must be limited to 3 days 5

Proper Administration Technique

Correct technique is critical to maximize efficacy and minimize side effects:

• Prime the bottle before first use and shake before each spray 4
• Have the patient blow their nose prior to administration 5
• Keep the head in an upright position during administration 5
• Hold the spray bottle in the opposite hand relative to the nostril being treated (contralateral technique) 5
• Direct the spray away from the nasal septum to reduce epistaxis risk by four times 5
• Breathe in gently during spraying 4
• Do not close the opposite nostril during administration 5
• If using nasal saline irrigations, perform them prior to the steroid spray 5

Common Side Effects

• Headache, pharyngitis, epistaxis (nosebleeds), and nasal burning or irritation are the most common adverse effects 4, 1
• Nausea, vomiting, asthma symptoms, and cough may also occur 4
• Local side effects like nasal irritation and bleeding are rare when proper administration technique is used 4
• The contralateral spray technique (using opposite hand for opposite nostril) significantly reduces epistaxis risk 5

Contraindications

• Hypersensitivity to fluticasone propionate or any component of the formulation is an absolute contraindication 4, 3

When to Escalate or Modify Therapy

• If no improvement occurs after 3 months of intranasal corticosteroid therapy at standard doses, consider adding a short course of oral corticosteroids or proceeding to CT imaging and surgical evaluation 5
• For moderate-to-severe allergic rhinitis with inadequate response to fluticasone alone, adding intranasal azelastine provides >40% relative improvement compared to either agent alone 5
• The combination product Dymista (azelastine 137 mcg + fluticasone 50 mcg per spray) is FDA-approved for patients ≥12 years at 1 spray per nostril twice daily 6