Flonase (Fluticasone Propionate) Nasal Spray Dosing for Allergic Rhinitis
For adults and adolescents ≥12 years, start with 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
Adult and Adolescent Dosing (≥12 years)
- Standard starting dose is 200 mcg once daily, administered as 2 sprays (50 mcg each) per nostril once daily in the morning. 1
- An alternative 200 mcg/day regimen can be given as 100 mcg twice daily (1 spray per nostril twice daily), though clinical trials showed no significant differences between once-daily and twice-daily administration. 1
- After 4-7 days of treatment, patients who have responded may be maintained on a reduced dose of 100 mcg/day (1 spray per nostril once daily). 1
- For seasonal allergic rhinitis specifically, some patients may use Flonase "as-needed" (not to exceed 200 mcg daily), though greater symptom control is achieved with scheduled regular use. 1
- Maximum total daily dose should not exceed 2 sprays per nostril (200 mcg/day), as exceeding the recommended dose has not been shown to be more effective. 1
Pediatric Dosing (4-11 years)
- Start with 100 mcg once daily (1 spray per nostril once daily). 1
- Reserve the 200 mcg dose (2 sprays per nostril once daily or 1 spray per nostril twice daily) only for children not adequately responding to 100 mcg daily. 1
- Once adequate control is achieved, decrease the dose back to 100 mcg (1 spray per nostril) daily. 1
- Maximum total daily dose should not exceed 2 sprays per nostril (200 mcg/day). 1
- Clinical trials in children ages 4-11 years demonstrated that 100 mcg once daily is as effective as 200 mcg once daily for seasonal allergic rhinitis. 2
Onset of Action and Treatment Duration
- Symptom improvement can begin as early as 12 hours after the first dose, but maximum effect may take several days to weeks of regular use. 1, 3
- 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. 4
- Flonase is a maintenance medication, not a rescue therapy—regular scheduled use is essential for optimal symptom control. 4, 3
Proper Administration Technique
To maximize efficacy and minimize side effects, instruct patients to: 4, 3
- Prime the bottle before first use
- Shake the bottle prior to each use
- Blow the nose before administering the spray
- Keep the head upright during administration
- Hold the spray bottle in the opposite hand relative to the nostril being treated (contralateral technique reduces epistaxis risk by 4-fold) 4
- Breathe in gently during spraying
- Direct the spray away from the nasal septum to minimize local irritation and bleeding 4
Common Side Effects
The most frequently reported adverse effects include: 4, 3, 1
- Headache
- Pharyngitis
- Epistaxis (nosebleeds)—occurs in 4-8% of patients
- Nasal burning or irritation
- Nausea, vomiting
- Cough
These side effects are generally mild and can be minimized with proper administration technique. 4, 3
Safety Considerations
- Fluticasone propionate at recommended doses has no effect on growth in children, hypothalamic-pituitary-adrenal axis function, or systemic cortisol levels. 4, 2, 5
- Contraindicated in patients with hypersensitivity to fluticasone propionate or any component of the formulation. 4, 3, 1
- Long-term use is safe and does not cause rhinitis medicamentosa (rebound congestion), unlike topical decongestants. 4
- Periodically examine the nasal septum during long-term use to detect mucosal erosions that may precede septal perforation (a rare complication). 4
Clinical Context: Regular vs. As-Needed Use
- For perennial allergic rhinitis, regular daily use is strongly recommended over as-needed use. 4
- For seasonal allergic rhinitis in adults and adolescents ≥12 years, as-needed use (not exceeding 200 mcg daily) may be effective for some patients, though regular use provides superior symptom control. 1
- As-needed use has not been studied in children under 12 years or in patients with perennial allergic rhinitis. 1
- For predictable seasonal patterns, initiate treatment before symptom onset and continue throughout the allergen exposure period for maximum effectiveness. 4