Is Flonase (fluticasone) nasal spray safe to use during pregnancy?

Flonase (Fluticasone) Nasal Spray Safety During Pregnancy

Flonase nasal spray can be safely used during pregnancy at recommended doses, though if initiating treatment during pregnancy, budesonide may be preferred due to more extensive human safety data. 1, 2

Safety Profile

Intranasal corticosteroids, including fluticasone, may be used during pregnancy because of their favorable safety and efficacy profile. 1 The evidence supporting this recommendation includes:

• A meta-analysis concluded that intranasal corticosteroids during pregnancy do not increase risks of major malformations, preterm delivery, low birth weight, or pregnancy-induced hypertension 1, 2
• Although animal studies with fluticasone showed fetal toxicity at high doses (including embryonic growth retardation, cleft palate, and retarded cranial ossification), rodents are more prone to teratogenic effects from corticosteroids than humans 3
• The FDA classifies fluticasone as Pregnancy Category C, meaning there are no adequate well-controlled studies in pregnant women, but it should be used only if potential benefits justify potential risks to the fetus 3
• Pharmacologic studies demonstrate much lower systemic exposure after intranasal versus oral corticosteroid administration, making the safety profile more favorable 1

Clinical Decision-Making Algorithm

If already using fluticasone before pregnancy:

• Continue fluticasone if it has adequately controlled symptoms, as no substantial difference in efficacy and safety exists among available intranasal corticosteroids 1, 2
• Use the lowest effective dose 1, 2

If initiating treatment during pregnancy:

• Budesonide (Pregnancy Category B) is preferred due to extensive human safety data 1, 2
• However, fluticasone furoate, mometasone, and budesonide are all considered safe at recommended therapeutic doses 4
• Fluticasone propionate may be used if other options are unavailable, though it has less robust pregnancy data than budesonide 4

Important Precautions

• Dose minimization is critical: Taper to the lowest effective dose that controls symptoms 1, 2
• First trimester considerations: This period carries the highest risk for medication-induced teratogenicity, though intranasal corticosteroids have not shown convincing evidence of congenital defects 1, 5
• Maternal side effects to monitor: Prolonged corticosteroid use may cause hyperglycemia, potential gestational diabetes, hypertension, and increased pre-eclampsia risk 2
• Drug interactions: Avoid coadministration with ritonavir or potent CYP3A4 inhibitors (like ketoconazole), as these can significantly increase systemic fluticasone exposure and cause Cushing syndrome or adrenal suppression 3

Common Pitfalls

• Assuming all intranasal corticosteroids have identical safety profiles: While generally safe as a class, budesonide has the most extensive human pregnancy data 1, 2
• Avoiding all medications unnecessarily: Untreated severe nasal symptoms can negatively impact maternal quality of life and potentially fetal well-being 5
• Using oral decongestants instead: These should be avoided, especially in the first trimester, due to associations with congenital malformations including gastroschisis and small intestinal atresia 1, 5