Can a healthcare provider prescribe Flonase (fluticasone) as needed?

Can Healthcare Providers Prescribe Flonase As Needed?

Yes, healthcare providers can prescribe Flonase (fluticasone propionate) as needed for patients 12 years and older with seasonal allergic rhinitis, though scheduled regular use provides superior symptom control. 1

FDA-Approved As-Needed Dosing

• The FDA label explicitly states that "some patients (12 years of age and older) with seasonal allergic rhinitis may find as-needed use of Fluticasone Propionate Nasal Spray (not to exceed 200 mcg daily) effective for symptom control." 1
• Two randomized, double-blind, placebo-controlled trials in 732 patients demonstrated that as-needed use (defined as using medication no more than 75% of study days) significantly reduced total nasal symptom scores compared to placebo. 1
• Patients in these trials used the medication an average of 57-70% of days, taking 200 mcg only on days when they needed symptom control, not exceeding once daily dosing. 1

Important Limitations of As-Needed Use

• The FDA label clearly states that "greater symptom control may be achieved with scheduled regular use" compared to as-needed dosing. 1
• As-needed use has NOT been studied in children under 12 years, patients with perennial allergic rhinitis, or patients with nonallergic rhinitis—these populations should use scheduled daily dosing only. 1
• The American Academy of Otolaryngology emphasizes that intranasal corticosteroids are maintenance therapy, not rescue therapy, and patients must understand this distinction to avoid premature discontinuation. 2

Optimal Dosing Strategy

• For as-needed use in eligible patients (≥12 years with seasonal allergic rhinitis): prescribe 200 mcg (2 sprays per nostril) once daily, used only on symptomatic days, not to exceed once daily. 1
• For regular scheduled use (all other patients): adults and adolescents ≥12 years should receive 200 mcg once daily or 100 mcg twice daily; children 4-11 years should receive 100 mcg once daily. 1
• The American Academy of Allergy, Asthma, and Immunology recommends that patients with predictable seasonal patterns should initiate treatment before symptom onset and continue throughout allergen exposure for maximum effectiveness. 2

Clinical Considerations for Prescribing

• Onset of action is delayed by approximately 12 hours, with maximal efficacy reached over days to weeks—counsel patients that immediate relief should not be expected. 2, 3
• Patients must be taught proper administration technique: use the contralateral hand (opposite hand for opposite nostril), aim the spray laterally away from the nasal septum, and keep the head upright during administration to reduce epistaxis risk by four times. 2, 3
• If nasal saline irrigations are used, perform them before administering fluticasone to avoid rinsing out the medication. 2, 3

Common Pitfalls to Avoid

• Do not prescribe as-needed use for children under 12 years—the efficacy and safety of this approach has not been established in this population. 1
• Avoid prescribing as-needed use for perennial allergic rhinitis or nonallergic rhinitis, as these conditions require continuous anti-inflammatory therapy for optimal control. 1
• Ensure patients understand that as-needed use may provide less symptom control than scheduled daily use, particularly for patients with moderate-to-severe symptoms. 1
• The most common error is improper spray technique with the nozzle aimed toward the septum rather than laterally, which increases epistaxis and reduces efficacy. 3