What is the recommended dose of Flonase (fluticasone propionate) for treating allergic rhinitis?

Flonase Dosing for Allergic Rhinitis

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

Age-Specific Dosing Recommendations

Adults and Adolescents (≥12 years)

• Initial dose: 200 mcg once daily (2 sprays per nostril once daily in the morning) 2, 1
• Alternative regimen: 100 mcg twice daily (1 spray per nostril twice daily), though once-daily dosing is equally effective 1, 3
• After 4-7 days of symptom control, may reduce to maintenance dose of 100 mcg once daily (1 spray per nostril) 1
• Maximum dose: Do not exceed 200 mcg/day (2 sprays per nostril); exceeding this dose provides no additional benefit 1

Children (4-11 years)

• Initial dose: 100 mcg once daily (1 spray per nostril once daily) 2, 1
• Reserve 200 mcg daily dosing only for children not adequately responding to 100 mcg 1
• Once adequate control achieved, decrease back to 100 mcg daily 1
• Both 100 mcg and 200 mcg doses are equally effective in children, with no advantage to higher dosing 4

Children Under 4 Years

• Fluticasone propionate (Flonase) is not FDA-approved for children under 4 years 2
• Consider alternative agents like mometasone furoate (approved for age ≥2 years) or triamcinolone acetonide (approved for age ≥2 years) 2

Special Dosing Considerations

Severe Nasal Congestion

• For severe congestion unresponsive to standard dosing, temporarily increase to 200 mcg twice daily, then reduce once symptoms are controlled 2, 5
• This higher dosing may be particularly beneficial for patients with severe congestion that has not responded to standard doses 2

As-Needed vs. Regular Use

• Regular scheduled use is superior to as-needed use for optimal symptom control 5, 1
• Some patients ≥12 years with seasonal allergic rhinitis may use as-needed dosing (not exceeding 200 mcg daily), though greater symptom control is achieved with scheduled regular use 1
• As-needed use has not been studied in children under 12 years 1

Onset and Duration of Effect

• Symptom improvement may begin as early as 12 hours after the first dose 1
• Maximum therapeutic effect requires several days to weeks of regular use 5, 1
• Patients must be counseled to continue therapy for at least 2 weeks after initiation, as full benefit may not be evident during this initial period 2

Proper Administration Technique

Critical for efficacy and minimizing side effects:

• Prime the bottle before first use and shake before each spray 2
• Have patient blow nose prior to using the spray 2
• Use contralateral hand technique (hold spray in opposite hand relative to nostril being treated) to direct spray away from nasal septum 2, 5
• Keep head upright during administration 2, 5
• Breathe in gently during spraying 2, 5
• Do not close the opposite nostril during administration 2, 5
• The contralateral spray technique reduces epistaxis risk by 4-fold compared to ipsilateral technique 2, 5

Safety Profile

Common Side Effects

• Headache, pharyngitis, epistaxis (nosebleeds), nasal burning/irritation, nausea, vomiting, and cough 2, 5
• Epistaxis is the most common adverse event with long-term use but remains generally mild 2
• Local side effects can be minimized with proper administration technique 2, 5

Systemic Safety

• No clinically significant hypothalamic-pituitary-adrenal axis suppression occurs at recommended doses in children or adults 2, 5, 4
• Studies show no effect on growth at recommended doses in children, even at up to twice the recommended doses 2
• Morning plasma cortisol concentrations remain normal in children treated with fluticasone propionate 4

Contraindications

• Contraindicated in patients with hypersensitivity to fluticasone or its components 2, 5

Long-Term Use

• Intranasal corticosteroids are safe for indefinite long-term use when clinically indicated 2
• Minimum treatment duration should be 8-12 weeks to properly assess therapeutic benefit 2
• For seasonal allergic rhinitis, initiate before symptom onset and continue throughout allergen exposure period 2
• Periodic examination of nasal septum is recommended during long-term use to detect mucosal erosions 2

When Initial Treatment Fails

• For inadequate response to fluticasone alone in patients ≥12 years with moderate-to-severe allergic rhinitis, add intranasal azelastine 5
• The combination of fluticasone propionate and azelastine shows >40% relative improvement compared to either agent alone 2
• If no improvement after 3 months, consider short course of oral corticosteroids or further evaluation 2