What is the proper dosage and usage of Flonase (fluticasone propionate)?

Flonase (Fluticasone Propionate) Dosage and Usage

Standard Dosing Recommendations

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

Age-Specific Dosing

Adults (≥12 years):

• Starting dose: 2 sprays (50 mcg each) per nostril once daily (200 mcg total) 1
• Alternative: 1 spray per nostril twice daily (100 mcg morning and evening) is equally effective 1
• Maintenance: After initial control, reduce to 1 spray per nostril once daily (100 mcg total) 1
• Maximum dose: Do not exceed 2 sprays per nostril daily (200 mcg) 1

Children (4-11 years):

• Starting dose: 1 spray per nostril once daily (100 mcg total) 1
• If inadequate response: May increase to 2 sprays per nostril once daily (200 mcg) 1
• Once controlled, decrease back to 1 spray per nostril daily 1
• Maximum dose: 2 sprays per nostril daily (200 mcg) 1

Children <4 years:

• Fluticasone propionate (Flonase) is not FDA-approved for children under 4 years 1
• For ages 2-3 years, consider fluticasone furoate (Veramyst) or mometasone furoate (Nasonex) as alternatives 2, 3

Proper Administration Technique

Critical steps to maximize efficacy and minimize side effects:

• Prime the bottle before first use by shaking and spraying until mist appears 2
• Shake the bottle before each use 2
• Have patient blow nose before administration 2
• Keep head upright during administration 2
• Use contralateral hand technique: Hold spray in opposite hand relative to the nostril being treated 2
• Direct spray away from nasal septum toward outer nasal wall (this reduces epistaxis risk by 4-fold) 2
• Breathe in gently during spraying 2
• Do not close the opposite nostril during administration 2
• If using nasal saline irrigations, perform them before the steroid spray 2

Treatment Duration and Timing

For optimal results, use at regular intervals rather than as-needed:

• Onset of action: 12 hours, with maximal efficacy reached in days to weeks 2
• For seasonal allergic rhinitis: Start before symptom onset and continue throughout allergen exposure period 2
• For perennial allergic rhinitis: Continue long-term with follow-up every 6 months if effective 2
• Once-daily morning dosing is as effective as twice-daily dosing for both seasonal and perennial allergic rhinitis 4, 5

Common Side Effects

Expected adverse effects include:

• Headache 3, 6
• Pharyngitis 3, 6
• Epistaxis (nosebleeds) 3, 6
• Nasal burning or irritation 3, 6
• Nausea or vomiting 3
• Cough 3

Important safety note: Proper contralateral spray technique significantly reduces epistaxis risk 2

Safety Considerations

Growth effects in children:

• No growth suppression occurs at recommended doses (200 mcg daily for one year showed equivalent growth to placebo) 7
• Studies with fluticasone propionate at recommended doses show no effect on growth compared to placebo 2

Hypothalamic-pituitary-adrenal (HPA) axis:

• No evidence of HPA axis suppression at recommended doses in children or adults 6, 5
• Morning plasma cortisol concentrations remain normal 6, 5

Long-term use:

• Safe for continuous daily use without risk of rhinitis medicamentosa (unlike topical decongestants which must be limited to 3 days) 2
• Periodically examine nasal septum during long-term use to detect mucosal erosions 2

Contraindications

Do not use in patients with:

• Hypersensitivity to fluticasone propionate or any component of the formulation 3, 1

When to Reassess Treatment

If inadequate response after 3 months of regular use:

• Consider adding intranasal antihistamine (azelastine) for combination therapy 2
• May consider short 5-7 day course of oral corticosteroids for severe symptoms 2
• Evaluate for alternative diagnoses or need for CT imaging 2

Clinical Efficacy Evidence

Fluticasone propionate is highly effective:

• More effective than oral antihistamines for all four major symptoms of allergic rhinitis 2
• More effective than leukotriene receptor antagonists 2
• Efficacy results from direct topical effects rather than systemic absorption 8
• Effective within 3 days of initiation with continued improvement throughout treatment 5