When is Flonase (fluticasone) spray used?

When to Use Flonase (Fluticasone) Nasal Spray

Flonase is indicated as first-line therapy for seasonal and perennial allergic rhinitis in adults and children ≥4 years of age, and can also be used for nonallergic rhinitis. 1

Primary Indications

Allergic Rhinitis

• Flonase is the most effective first-line treatment for allergic rhinitis, superior to oral antihistamines, leukotriene antagonists, and intranasal antihistamines for controlling all four major nasal symptoms: congestion, rhinorrhea, sneezing, and itching 2, 3
• It is FDA-approved for both seasonal and perennial allergic rhinitis in patients ≥4 years of age 1
• Intranasal corticosteroids like Flonase are significantly more effective than oral and intranasal antihistamines in relieving symptoms of sneezing, nasal congestion, discharge, and itching 2

Nonallergic Rhinitis

• Flonase is effective for certain forms of nonallergic rhinitis, particularly NARES (nonallergic rhinitis with eosinophilia syndrome) and vasomotor rhinitis 2
• Studies demonstrate effectiveness in patients with perennial nonallergic rhinitis for symptoms of nasal obstruction, postnasal drip, and rhinorrhea 1

Additional Symptom Relief

• Flonase provides significant relief of sinus pain and pressure associated with allergic rhinitis, not just the classic nasal symptoms 4

Age-Specific Dosing

Adults and Adolescents (≥12 years)

• Start with 200 mcg once daily (2 sprays per nostril) 1
• Alternative regimen: 100 mcg twice daily (1 spray per nostril twice daily) 1
• After 4-7 days of response, may reduce to maintenance dose of 100 mcg daily (1 spray per nostril once daily) 1
• Maximum dose: 200 mcg/day (2 sprays per nostril) 1

Children (4-11 years)

• Start with 100 mcg once daily (1 spray per nostril) 5, 1
• Reserve 200 mcg daily for children not adequately responding to 100 mcg 1
• Once control is achieved, decrease to 100 mcg daily 1
• Maximum dose: 200 mcg/day 1

Important Age Restriction

• Flonase is NOT approved for children under 4 years of age 1
• For children 2-3 years, consider fluticasone furoate (Veramyst) or triamcinolone acetonide (Nasacort) instead 3, 5

Timing and Duration of Use

Onset of Action

• Symptom relief begins within 12 hours, with some patients experiencing relief as early as 3-4 hours 2
• Maximum therapeutic effect develops over several days to weeks 3

Regular vs. As-Needed Use

• Regular daily use is most effective for optimal symptom control 1
• For seasonal allergic rhinitis in patients ≥12 years, as-needed use (not exceeding 200 mcg daily) may be effective for some patients, though regular use provides greater symptom control 1, 6
• As-needed use has not been studied in children under 12 years or in perennial/nonallergic rhinitis 1

Treatment Duration

• Minimum treatment duration: 2 weeks to assess benefit 3
• For seasonal allergic rhinitis: initiate before symptom onset and continue throughout allergen exposure period 3
• Long-term daily use is safe and does not cause rebound congestion (unlike topical decongestants which must be limited to 3 days) 3
• Studies demonstrate safety for continuous use up to 6 months and beyond 1, 7

Clinical Scenarios for Use

When Nasal Airway is Blocked

• If nasal congestion is severe, use a nasal decongestant spray for several days when initiating Flonase to ensure adequate intranasal delivery 2
• This is a common pitfall—patients need a patent airway for optimal drug delivery 2

Severe or Refractory Symptoms

• For severe nasal congestion unresponsive to standard dosing, consider higher dosing (2 sprays per nostril twice daily initially), then reduce to maintenance once controlled 3
• If no improvement after 3 months, reassess and consider adding oral corticosteroids or further evaluation 3

Combination Therapy

• If Flonase alone is inadequate for moderate-to-severe allergic rhinitis, adding an intranasal antihistamine (azelastine) provides the greatest additional benefit 3
• Adding oral antihistamines to Flonase generally does not provide significant additional benefit in controlled trials, though some patients may require both 2

Safety Profile

Systemic Effects

• At recommended doses, Flonase does not cause clinically significant systemic corticosteroid effects 2
• No effect on HPA axis, morning cortisol levels, or 24-hour urinary cortisol excretion 2, 3
• Studies show no effect on growth in children at recommended doses (fluticasone propionate, mometasone, and budesonide) 3

Local Side Effects

• Most common: headache, pharyngitis, epistaxis (nosebleeds), nasal burning/irritation, nausea, and cough 3, 5
• Proper technique minimizes epistaxis: direct spray away from nasal septum and use contralateral hand (right hand for left nostril) 3
• Long-term use does not cause nasal mucosal atrophy 3

Monitoring

• Periodically examine nasal septum during long-term use to detect mucosal erosions that may precede septal perforation (rare complication) 3

Contraindications

• Hypersensitivity to fluticasone or any component of the formulation 5