Fluticasone Propionate HFA 0.22mg/Actuation Dosing
For adults and adolescents ≥12 years with asthma, start with 88 mcg (one inhalation of the 0.22mg/actuation formulation) twice daily, which can be increased to 220 mcg (one inhalation) twice daily for moderate disease or 440 mcg (two inhalations) twice daily for severe disease, with a maximum of 880 mcg total daily dose. 1, 2, 3
Age-Specific Dosing Guidelines
Adults and Adolescents (≥12 years)
- Low dose: 88-264 mcg/day (one inhalation of 88 mcg twice daily to 1.5 inhalations twice daily) 1, 2
- Medium dose: >264-440 mcg/day (approximately 1.5-2 inhalations twice daily) 1, 2
- High dose: >440 mcg/day (two inhalations twice daily, maximum 880 mcg/day) 1, 2
- The 0.22mg/actuation formulation delivers 220 mcg from the valve, which corresponds to approximately 200 mcg delivered dose 4
Children (5-11 years)
- Low dose: 88-176 mcg/day (one inhalation once or twice daily) 1, 2
- Medium dose: >176-352 mcg/day (one to two inhalations twice daily) 1, 2
- High dose: >352 mcg/day (maximum two inhalations twice daily) 1, 2
Young Children (1-4 years)
- Recommended dose: 88 mcg twice daily via metered-dose inhaler with valved holding chamber and facemask 5
- Low dose: 176 mcg/day 1, 2
- Medium dose: >176-352 mcg/day 1, 2
- High dose: >352 mcg/day 1, 2
- This age group requires delivery through a properly fitted facemask to ensure adequate drug delivery 1
Dose-Response and Titration Strategy
The dose-response curve for fluticasone is relatively flat above 200-250 mcg/day, meaning minimal additional clinical benefit occurs at higher doses while systemic side effect risk increases substantially. 2
- Most patients achieve optimal asthma control at 200-250 mcg total daily dose (approximately one inhalation of 88-110 mcg twice daily) 2
- In a dose-ranging study, 100 mcg, 250 mcg, and 500 mcg twice daily showed essentially no differences in efficacy among the three groups 4
- Once control is achieved, titrate down by 25-50% at each step to the minimum effective dose 2
Administration Technique
Proper inhaler technique is critical—use a spacer or valved holding chamber with metered-dose inhalers to reduce local side effects and improve drug delivery. 1, 6, 2
- Rinse mouth and spit after each use to prevent oral candidiasis 1, 6, 2
- For children <4 years, use a facemask that fits snugly over nose and mouth 1
- Administer twice daily (e.g., 8 AM and 8 PM) for optimal asthma control 2, 3
Maximum Dosing Limits and Safety Considerations
The maximum recommended daily dose is 880 mcg (440 mcg twice daily), as higher doses significantly increase systemic side effect risk without meaningful additional clinical benefit. 6, 2
- Doses >1000 mcg/day are associated with increased risk of adrenal suppression, bone loss, osteoporosis, skin thinning, and bruising 1, 6, 2
- In children, growth velocity suppression has been observed with inhaled corticosteroids, though this effect may be transient 1, 6, 2
- Systemic effects are minimal at low-to-medium doses (≤440 mcg/day) 2
Common Adverse Effects
Local effects include pharyngitis, oral thrush (candidiasis), dysphonia, and cough, which can be minimized with proper spacer use and mouth rinsing. 1, 6, 2
- Treatment-related adverse events occurred in 13-15% of fluticasone-treated patients, mainly localized to the oropharynx/larynx 4
- In preschool children, fluticasone HFA 88 mcg twice daily was well tolerated with similar adverse event rates to placebo 5
- Baseline urinary cortisol excretion showed little change from baseline at endpoint in pediatric studies 5
Clinical Efficacy Data
Fluticasone propionate demonstrates superior efficacy compared to placebo across all age groups, with significant improvements in lung function, symptom scores, and reduced rescue medication use. 4, 5, 7
- In adults with moderate asthma, all fluticasone doses (100-500 mcg twice daily) significantly improved FEV1 compared to placebo, with 72% of placebo patients withdrawn for lack of asthma stability versus only 13-16% of fluticasone-treated patients 4
- In preschool children, fluticasone HFA 88 mcg twice daily produced significantly greater reductions in 24-hour daily asthma symptom scores (-53.9% vs -44.1% for placebo) 5
- Fluticasone propionate is at least twice as potent as beclomethasone dipropionate, budesonide, or triamcinolone acetonide 8