How do you prescribe Flonase (fluticasone) as needed?

How to Prescribe Flonase As-Needed

Flonase (fluticasone propionate) can be prescribed as-needed for adults and adolescents ≥12 years with seasonal allergic rhinitis at 200 mcg daily (2 sprays per nostril once daily), but regular scheduled use is more effective for optimal symptom control. 1, 2

Evidence for As-Needed Use

The FDA label explicitly supports as-needed use for patients ≥12 years with seasonal allergic rhinitis, based on two randomized controlled trials demonstrating significantly greater reduction in total nasal symptom scores compared to placebo when used on days patients felt they needed symptom control. 2

• In FDA trials, "as-needed" was defined as using medication no more than 75% of study days, with actual usage ranging from 55-70% of days. 1, 2
• Symptom relief can begin within 12 hours of administration, though maximum effect takes several days. 1, 2
• One study showed fluticasone as-needed was significantly better than loratadine as-needed for activity, sleep, and overall quality of life domains. 1

Important Limitations of As-Needed Approach

Regular scheduled use is superior to as-needed use for most patients. 1, 3

• Guidelines explicitly state patients should use intranasal corticosteroids regularly to maintain symptom control and not apply an as-needed approach. 1
• A 2021 randomized trial found regular use tended toward greater improvement in total nasal symptom scores compared to as-needed use (though the difference did not reach statistical significance, P=0.066). 4
• Regular use produced significantly better nasal peak inspiratory flow improvement compared to as-needed use (-19.21 L/min difference, P=0.009). 4
• As-needed use resulted in only 51% of the corticosteroid exposure compared to regular use, which may be relevant for patients concerned about steroid exposure. 4

Prescribing Instructions for As-Needed Use

For adults and adolescents ≥12 years with seasonal allergic rhinitis:

• Prescribe 200 mcg daily (2 sprays per nostril once daily) to be used on days when symptoms require control. 2
• Maximum dose: Do not exceed 2 sprays per nostril per day, and use no more than once daily. 2
• Counsel patients that greater symptom control may be achieved with scheduled regular use rather than as-needed use. 2

As-needed use has NOT been studied and is NOT recommended for:

• Pediatric patients <12 years with seasonal allergic rhinitis 2
• Any patients with perennial allergic rhinitis 2
• Any patients with nonallergic rhinitis 2

Proper Administration Technique

Use the contralateral hand technique to minimize epistaxis risk by four times:

• Hold the spray bottle in the opposite hand from the nostril being treated (right hand for left nostril, left hand for right nostril). 3, 5
• Aim the nozzle laterally toward the outer nasal wall, away from the nasal septum. 3, 5
• Keep head upright during administration. 1, 3
• Prime the pump 6 times before first use or if unused for ≥7 days. 2
• Blow nose to clear secretions before spraying. 1, 2
• Breathe in gently during spraying. 1, 2
• If using nasal saline irrigations, perform them prior to fluticasone administration to avoid rinsing out the medication. 1, 3

Patient Counseling Points

Set realistic expectations about onset and efficacy:

• Onset of action occurs within 12 hours, but maximal efficacy takes days to weeks. 1, 3
• For predictable seasonal patterns, starting before symptom onset and continuing throughout allergen exposure is most effective. 3
• As-needed use may not provide the same level of symptom control as regular scheduled use. 2, 4

Common side effects include:

• Headache, pharyngitis, epistaxis, nasal burning/irritation, nausea, and cough. 1, 3
• Proper spray technique (contralateral hand, aiming away from septum) reduces epistaxis risk significantly. 3, 5

When As-Needed Use Is Inappropriate

Switch to regular scheduled use if:

• Patient has perennial allergic rhinitis or nonallergic rhinitis (as-needed use not studied in these populations). 2
• Patient is <12 years old (as-needed use not studied in pediatric patients). 2
• Symptoms are not adequately controlled with as-needed use. 2
• Patient has moderate-to-severe persistent symptoms requiring consistent control. 1, 3

For patients requiring regular use:

• Adults/adolescents ≥12 years: Start with 200 mcg once daily (2 sprays per nostril), may reduce to 100 mcg once daily (1 spray per nostril) for maintenance after 4-7 days if adequate control achieved. 2
• Children 4-11 years: Start with 100 mcg once daily (1 spray per nostril), may increase to 200 mcg daily if inadequate response, then reduce to 100 mcg for maintenance. 2