Can Flonase (fluticasone) cause an increase in intraocular pressure (IOP)?

Can Flonase Cause an Increase in IOP?

Yes, Flonase (fluticasone propionate nasal spray) can cause an increase in intraocular pressure, though this occurs rarely. The FDA label explicitly states that "rare instances of glaucoma and increased intraocular pressure have been reported following the intranasal application of corticosteroids, including fluticasone propionate" 1.

Mechanism and Risk

• All corticosteroid formulations carry risk for IOP elevation, regardless of route of administration—topical, periocular, systemic, or intranasal 2, 3.
• The mechanism involves morphological and functional changes in the trabecular meshwork system, similar to primary open-angle glaucoma pathogenesis 2.
• Approximately 18-36% of the general population are "corticosteroid responders," meaning they experience IOP elevation with steroid exposure 2.

High-Risk Populations

Patients with the following characteristics are at substantially increased risk:

• Primary open-angle glaucoma (POAG): 46-92% of these patients are steroid responders, compared to 18-36% of the general population 2.
• Age over 40 years 2.
• Family history of POAG 2, 3.
• Diabetes mellitus or high myopia 2.

Clinical Evidence Specific to Intranasal Fluticasone

• A 2-year randomized controlled trial of fluticasone furoate nasal spray (110 μg once daily) in 548 patients with perennial allergic rhinitis found no statistically significant difference in IOP events compared to placebo (P = 0.34) 4.
• However, a retrospective study of 12 glaucoma patients using nasal steroids demonstrated a significant IOP increase during nasal steroid use (mean 18.0 mm Hg) compared to pre-steroid baseline (mean 15.4 mm Hg, P = 0.007) 5.
• Upon discontinuation of nasal steroids, IOP decreased significantly back to baseline levels (mean 14.5 mm Hg, P < 0.001), with 11 of 12 patients experiencing IOP reduction at a mean of 35 days after stopping the medication 5.

Clinical Recommendations

For patients with glaucoma or at high risk:

• Inquire about glaucoma history before initiating nasal corticosteroids 5.
• Monitor IOP regularly during treatment, particularly in the first 2-8 weeks when steroid-induced pressure elevation typically occurs 6, 3.
• Consider discontinuing nasal steroids if IOP elevation occurs, as this can allow many patients to meet target pressures and avoid additional glaucoma therapy 5.
• The American Academy of Ophthalmology emphasizes that patients using long-term topical corticosteroids should have IOP checked at regular intervals to rule out corticosteroid-induced IOP elevation 7.

Important Caveats

• The risk is dose-dependent: larger than recommended doses increase the likelihood of systemic corticosteroid effects, including IOP elevation 1.
• Individual steroid responsiveness varies widely—some patients will never experience IOP elevation, while others are highly sensitive 2, 3.
• The FDA label warns that if hypercorticism or adrenal suppression occurs with intranasal fluticasone, "the dosage should be discontinued slowly consistent with accepted procedures for discontinuing oral corticosteroid therapy" 1.