What is the proper dosing and administration of mometasone (mometasone furoate) nasal spray?

How to Prescribe Mometasone Nasal Spray

For adults and children ≥12 years with allergic rhinitis, prescribe mometasone furoate nasal spray 2 sprays per nostril once daily (200 mcg total daily dose); for children ages 2-11 years, prescribe 1 spray per nostril once daily (100 mcg total daily dose). 1, 2

Age-Specific Dosing

Children 2-11 Years

• Prescribe 1 spray (50 mcg) per nostril once daily for a total of 100 mcg/day 1, 2, 3
• This dose has been validated in clinical trials showing superior efficacy compared to lower doses (25 mcg) and equivalent efficacy to higher doses (200 mcg) without additional benefit 3
• An adult should supervise administration in this age group 4
• Check with the child's physician if treatment extends beyond two months per year 4

Adolescents and Adults ≥12 Years

• Prescribe 2 sprays (50 mcg each) per nostril once daily for a total of 200 mcg/day 1, 2, 5
• This is the FDA-approved dose for both seasonal and perennial allergic rhinitis 5, 6

Adults with Nasal Polyps

• Prescribe 2 sprays per nostril twice daily for a total of 400 mcg/day 2
• The twice-daily regimen is specifically indicated for nasal polyps due to the more severe inflammatory burden 2
• Clinical evidence from post-viral rhinosinusitis demonstrates that 200 mcg twice daily produces significantly greater symptom improvements compared to once-daily dosing 7, 2

Proper Administration Technique

Teaching correct technique is critical—improper use increases local side effects and reduces efficacy. 1

Step-by-Step Instructions (from FDA Label)

1. Prime the bottle before first use by pumping until fine mist appears; also prime if bottle hasn't been used in one week or after cleaning nozzle 4
2. Shake the bottle well before each use 1, 4
3. Have patient blow nose gently to clear nostrils 1, 4
4. Keep head upright during administration 1
5. Use contralateral hand technique: hold spray in opposite hand relative to the nostril being treated (e.g., right hand for left nostril) 1
6. Aim spray away from nasal septum toward the outer wall of the nose—this reduces epistaxis risk by four times compared to aiming toward the septum 1
7. Insert just the tip of the nozzle into the nostril 4
8. Breathe in gently while spraying, then breathe out through mouth 4
9. Do not close the opposite nostril during administration 1
10. Wipe nozzle with clean tissue and replace cap 4

If Using Nasal Saline Irrigations

• Perform saline irrigations before administering the steroid spray 1

Onset of Action and Patient Counseling

• Counsel patients that onset of action is delayed approximately 12 hours, with maximal efficacy reached in days to weeks 1, 2
• Emphasize regular daily use rather than as-needed approach to maintain symptom control 1, 2
• If allergy symptoms do not improve after one week, stop using and consult a physician 4
• This is maintenance therapy, not rescue therapy—do not discontinue when symptoms improve 1

Duration of Treatment

• Prescribe for a minimum of 8-12 weeks to allow adequate time for symptomatic relief and proper assessment of therapeutic benefit 1
• Long-term daily use is safe and does not cause rhinitis medicamentosa (unlike topical decongestants which must be limited to 3 days) 1
• Evidence supports indefinite use when clinically indicated, with no effect on systemic cortisol levels or hypothalamic-pituitary-adrenal axis function 1, 8, 3
• For predictable seasonal patterns, initiate before symptom onset and continue throughout allergen exposure period 1

Safety Profile and Common Side Effects

• Most common adverse events are headache, viral infection, pharyngitis, epistaxis (nosebleeds), and cough—all generally mild to moderate 2, 6
• Epistaxis occurs in 4-8% over short periods and up to 20% over one year, but proper spray technique (directing away from septum) minimizes this risk 1
• Growth effects are not a concern: studies with mometasone furoate at recommended doses show no effect on growth compared to placebo in children 1, 8, 3
• No evidence of hypothalamic-pituitary-adrenal axis suppression in studies up to one year 8, 3, 6
• Nasal mucosa biopsies from patients treated continuously for 1-5 years show no evidence of atrophy 1

Contraindications

• Do not prescribe if patient has hypersensitivity to mometasone or any component of the formulation 1, 2
• Do not spray in eyes; if accidental exposure occurs, rinse well with water 4

Monitoring During Long-Term Use

• Periodically examine the nasal septum to detect mucosal erosions that may precede septal perforation (a rare complication) 1
• Consider ophthalmic monitoring for patients on long-term therapy, though no increased risk of lens opacity, elevated intraocular pressure, or glaucoma has been associated with prolonged use 1
• One-year safety studies in children showed no significant changes in intraocular pressure 8

Maintenance Instructions

• Clean spray nozzle weekly or if clogged by removing nozzle, rinsing under running tap water, and drying at room temperature 4
• Do not try to unblock nozzle with pin or sharp object as this can damage it 4
• If clogged, soak in warm water then re-prime 4
• Do not share bottle with anyone else as this may spread germs 4
• Store between 20-25°C (68-77°F) 4

When Treatment Fails

• If no improvement after 3 months of intranasal corticosteroid therapy, consider adding a short course of oral corticosteroids or proceeding to CT imaging and surgical evaluation 1
• For inadequate response to mometasone alone, consider adding an intranasal antihistamine (e.g., azelastine combined with fluticasone propionate shows >40% relative improvement compared to either agent alone) 1
• Alternative intranasal corticosteroids like fluticasone propionate or triamcinolone acetonide may be tried if mometasone is not tolerated 1