Fluticasone Propionate (Flonase) Nasal Spray: Dosage and Pharmacokinetics
Recommended Dosage
For adults and adolescents ≥12 years, start with 2 sprays (50 mcg each) in each nostril once daily (total 200 mcg/day), which can be reduced to 1 spray per nostril once daily for maintenance after the first few days. 1
Age-Specific Dosing
Adults and Adolescents (≥12 years):
- Initial dose: 2 sprays per nostril once daily (200 mcg total) 1
- Alternative regimen: 100 mcg twice daily (1 spray per nostril at 8 AM and 8 PM) is equally effective 1
- Maintenance: After initial control, reduce to 1 spray per nostril once daily (100 mcg total) 1
- As-needed use: For seasonal allergic rhinitis, 200 mcg once daily can be used as needed (not daily), though scheduled regular use provides greater symptom control 1
Children (4-11 years):
- Initial 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 total) 1
- Once controlled: Decrease back to 100 mcg daily 1
- Maximum: Do not exceed 2 sprays per nostril daily (200 mcg/day) 1
- Not recommended for children under 4 years of age 1
Clinical Trial Evidence on Dosing
There is no clear dose-response relationship beyond 200 mcg/day—higher doses do not provide additional benefit. 1 Studies demonstrate that 200 mcg once daily is as effective as 100 mcg twice daily for both adults and children 1, 2, 3. In children aged 4-11 years, 100 mcg once daily is as effective as 200 mcg once daily 4.
Pharmacokinetic Profile
Fluticasone propionate's efficacy results entirely from direct topical effects on nasal mucosa, not systemic absorption. 5
Absorption and Systemic Bioavailability
- The swallowed portion has negligible systemic bioavailability due to extensive first-pass metabolism and poor gastrointestinal absorption 6, 5
- Only the drug absorbed through nasal mucosa contributes to any systemic exposure 6
- A study comparing intranasal 200 mcg versus oral doses of 5-10 mg demonstrated that oral fluticasone (despite 25-50 times higher doses) produced no therapeutic effect, confirming purely topical mechanism 5
- Plasma concentrations after intranasal administration are minimal and clinically insignificant 5
Onset and Duration of Action
- Symptom relief begins as early as 12 hours after the first dose 1
- Maximum therapeutic effect requires several days to weeks of regular use 7, 1
- This delayed maximal efficacy necessitates patient counseling about continuing therapy for at least 2 weeks before assessing benefit 7
Proper Administration Technique
Using the contralateral hand technique (right hand for left nostril, left hand for right nostril) reduces epistaxis risk by four-fold compared to ipsilateral technique. 7, 8
Step-by-Step Instructions
- Prime the bottle before first use 7
- Shake the bottle prior to each use 7
- Have patient blow nose before administration 7
- Keep head upright during administration 7
- Direct spray away from nasal septum (aim toward outer wall of nostril) 7
- Breathe in gently during spraying 7
- Do not close the opposite nostril during administration 7
- If using nasal saline irrigations, perform them before the steroid spray 7
Safety Profile
Hypothalamic-Pituitary-Adrenal (HPA) Axis Effects
At recommended doses, fluticasone propionate does not cause clinically significant HPA axis suppression in children or adults. 7, 6, 4 Morning plasma cortisol concentrations remain normal in pediatric patients receiving therapeutic doses 4.
Growth Effects in Children
Studies with fluticasone propionate at recommended doses show no effect on growth compared to placebo, even at twice the recommended dose. 7 This makes it safe for long-term use in pediatric populations when clinically indicated 7.
Common Adverse Effects
- Headache 7
- Pharyngitis 7
- Epistaxis (nosebleeds)—occurs in 4-8% short-term, up to 20% with one year of use 7
- Nasal burning or irritation 7
- Nausea and vomiting 7
- Cough 7
Proper spray technique directing away from the septum minimizes epistaxis and local irritation. 7, 8
Rare but Serious Complications
- Nasal septal perforation is rare but possible with long-term use 7
- Periodically examine the nasal septum during long-term therapy to detect mucosal erosions that may precede perforation 7
Duration of Treatment
Intranasal corticosteroids are safe for indefinite long-term use when clinically indicated, as they do not cause systemic effects, HPA axis suppression, or rhinitis medicamentosa. 7
Treatment Duration Guidelines
- Minimum initial trial: 8-12 weeks to properly assess therapeutic benefit 7
- For seasonal allergic rhinitis: Initiate before symptom onset and continue throughout allergen exposure period 7
- For perennial rhinitis: Continue long-term with follow-up every 6 months if effective 7
- Unlike topical decongestants (limited to 3 days), intranasal corticosteroids do not cause rebound congestion and are safe for daily long-term use 7
When to Reassess or Escalate
- If no improvement after 3 months of monotherapy, consider adding intranasal antihistamine or short course of oral corticosteroids 7
- For inadequate response to fluticasone alone, adding azelastine (intranasal antihistamine) provides >40% greater symptom reduction than either agent alone 7, 8
Contraindications
Fluticasone propionate is contraindicated in patients with hypersensitivity to fluticasone or any component of the formulation. 7
Key Clinical Pitfalls to Avoid
- Do not discontinue therapy when symptoms improve—intranasal corticosteroids are maintenance therapy, not rescue therapy 7
- Counsel patients that full benefit may not occur for 2 weeks—premature discontinuation due to perceived lack of efficacy is common 7
- Ensure proper administration technique is taught—improper use increases local side effects and reduces efficacy 7, 8
- Do not exceed 200 mcg/day in children—there is no evidence that higher doses are more effective 1