What is the recommended dosage and usage of Flonase (fluticasone propionate)?

Flonase (Fluticasone Propionate) Dosage and Usage

Recommended Dosing by Age

For adults and adolescents ≥12 years, use 2 sprays per nostril once daily (200 mcg total dose); for children ages 4-11 years, use 1 spray per nostril once daily (100 mcg total dose). 1

Adult Dosing (≥12 years)

• Starting dose: 2 sprays (50 mcg each) per nostril once daily = 200 mcg total daily dose 1
• Alternative regimen: 100 mcg twice daily (e.g., 8 AM and 8 PM) is equally effective 1
• Maintenance dose: After the first few days, many patients can reduce to 1 spray per nostril once daily (100 mcg total) 1
• Maximum dose: Do not exceed 2 sprays per nostril daily (200 mcg/day) 1

Pediatric Dosing (4-11 years)

• Starting dose: 1 spray per nostril once daily = 100 mcg total 1
• If inadequate response: May increase to 2 sprays per nostril once daily = 200 mcg 1
• Once controlled: Decrease back to 1 spray per nostril daily 1
• Maximum dose: 2 sprays per nostril (200 mcg/day) 1

Age Restrictions

• Not recommended for children <4 years of age 1
• For children ages 2-3 years requiring intranasal steroid therapy, consider fluticasone furoate (Veramyst) or mometasone furoate (Nasonex), which are FDA-approved for this age group 2, 3

Proper Administration Technique

Direct the spray away from the nasal septum using the contralateral hand technique to reduce epistaxis risk by four times. 2

Step-by-Step Instructions

• Prime the bottle before first use 2
• Shake the bottle prior to each use 2
• Have the patient blow their nose before administration 2
• Keep head upright during administration 2
• Hold the spray in the opposite hand relative to the nostril being treated (right hand for left nostril, left hand for right nostril) 2
• Breathe in gently during spraying 2
• Do not close the opposite nostril during administration 2
• If using nasal saline irrigations, perform them before administering Flonase to avoid rinsing out the medication 2

Onset and Duration of Action

Patients must understand that symptom relief may be delayed 12 hours with maximal efficacy reached in days to weeks, requiring regular scheduled use rather than as-needed dosing. 2

• Initial symptom improvement typically occurs within the first 7 days 4
• Full therapeutic benefit requires consistent daily use for optimal effect 1
• For seasonal allergic rhinitis with predictable patterns, initiate treatment before symptom onset and continue throughout allergen exposure 2

Common Side Effects

The most common adverse effects include 2, 3, 1:

• Headache
• Pharyngitis
• Epistaxis (nosebleeds) - occurs in 4-8% short-term, up to 20% with one year of use 2
• Nasal burning or irritation
• Nausea or vomiting
• Cough
• Asthma symptoms

Safety Profile for Long-Term Use

Intranasal fluticasone propionate is safe for indefinite long-term use when clinically indicated, with no clinically significant effects on growth, HPA axis function, or ocular complications at recommended doses. 2

Systemic Safety

• No consistent effects on hypothalamic-pituitary-adrenal (HPA) axis in children or adults 2
• Studies demonstrate safety for up to 52 weeks of continuous use 2
• Morning plasma cortisol concentrations remain normal 5
• No increased risk of lens opacity, elevated intraocular pressure, or glaucoma 2

Pediatric Growth Considerations

• Fluticasone propionate, mometasone furoate, and budesonide show no effect on growth at recommended doses compared to placebo 2
• Studies show no growth suppression even at up to twice the recommended doses 2
• Growth suppression has only been reported with beclomethasone dipropionate exceeding recommended doses 2

Local Safety

• Nasal mucosa biopsies from patients treated continuously for 1-5 years show no evidence of atrophy 2
• Periodically examine the nasal septum to detect mucosal erosions that may precede septal perforation (rare complication) 2
• Proper spray technique directing away from septum minimizes local side effects 2

Contraindications

Flonase is contraindicated in patients with hypersensitivity to fluticasone propionate or any component of the formulation. 2, 3

Treatment Duration Guidelines

A minimum treatment duration of 8-12 weeks is recommended to allow adequate time for symptomatic relief and proper assessment of therapeutic benefit. 2

• Counsel patients to continue therapy for at least 2 weeks after initiation, as full benefit may not be evident during this period 2
• For seasonal allergic rhinitis, continue throughout the allergen exposure period 2
• Long-term daily use is safe and does not cause rhinitis medicamentosa (unlike topical decongestants, which must be limited to 3 days maximum) 2
• If no improvement after 3 months, consider adding oral corticosteroids short-term or proceeding to further evaluation 2

When to Escalate Therapy

For patients with inadequate response to standard once-daily dosing, increase to twice-daily dosing (200 mcg twice daily) particularly for severe nasal congestion, then reduce to maintenance dosing once symptoms are controlled. 2

• Higher dosing may be beneficial for severe nasal congestion unresponsive to standard dosing 2
• Once adequate control is achieved, step down to the lowest effective maintenance dose 1
• If intranasal corticosteroid monotherapy fails, add intranasal antihistamine (azelastine) for combination therapy, which shows >40% relative improvement over either agent alone 2