What is the recommended dosage for Flonase (fluticasone propionate) for allergic rhinitis?

Flonase (Fluticasone Propionate) Dosing for Allergic Rhinitis

For adults and adolescents ≥12 years, start with 2 sprays per nostril once daily (200 mcg total), administered in the morning; for children 4-11 years, use 1 spray per nostril once daily (100 mcg total). 1

Adult and Adolescent Dosing (≥12 years)

The standard starting dose is 200 mcg once daily, delivered as 2 sprays (50 mcg each) per nostril in the morning. 1 This can alternatively be divided into 100 mcg twice daily (1 spray per nostril twice daily), though clinical trials showed no significant differences between once-daily and twice-daily regimens. 1

• After 4-7 days of treatment, patients who have responded may be maintained on a reduced dose of 100 mcg daily (1 spray per nostril once daily). 1
• Maximum daily dose should not exceed 200 mcg (2 sprays per nostril); exceeding this dose has not been shown to provide additional benefit. 1
• Onset of symptom relief occurs as early as 12 hours after the first dose, but maximal efficacy requires several days to weeks of regular use. 1, 2

Pediatric Dosing (4-11 years)

Children should start with 100 mcg once daily (1 spray per nostril). 1 The 200 mcg dose (2 sprays per nostril once daily or 1 spray twice daily) should be reserved only for children not adequately responding to 100 mcg daily. 1

• Once adequate control is achieved, decrease back to 100 mcg daily. 1
• Clinical trials in children as young as 4 years demonstrated that 100 mcg once daily is as effective as the 200 mcg adult dose for seasonal allergic rhinitis. 3
• Fluticasone propionate is FDA-approved for children ≥4 years of age. 4

Administration Technique

Proper spray technique is critical to minimize side effects, particularly epistaxis. 4, 2

• Use the contralateral hand technique (right hand for left nostril, left hand for right nostril) to naturally direct the spray away from the nasal septum—this reduces epistaxis risk by four-fold. 4, 2
• Prime the bottle before first use and shake before each administration. 4
• Have the patient blow their nose prior to spraying. 4
• Keep the head upright during administration and breathe in gently during spraying. 4
• Do not close the opposite nostril during administration. 4
• If using nasal saline irrigations, perform them before administering fluticasone to avoid rinsing out the medication. 4, 2

Duration of Treatment

Fluticasone should be used at regular intervals as maintenance therapy, not as-needed rescue therapy. 1 Long-term use is both safe and effective, with studies demonstrating safety for up to 52 weeks of continuous use. 4

• For seasonal allergic rhinitis, initiate treatment before symptom onset and continue throughout the allergen exposure period. 4
• Minimum treatment duration should be 8-12 weeks to properly assess therapeutic benefit. 4
• Patients must be counseled to continue therapy for at least 2 weeks after initiation, as full benefit may not be evident during this early period. 4
• Unlike topical decongestants (which cause rebound congestion after 3 days), intranasal corticosteroids do not cause rhinitis medicamentosa and are safe for long-term daily use. 4

Safety Considerations

Common side effects include headache, pharyngitis, epistaxis, nasal burning/irritation, nausea, and cough, all generally mild to moderate. 4, 2

• Fluticasone propionate, mometasone furoate, and budesonide show no effect on growth at recommended doses in children, even at up to twice the recommended doses. 4
• Studies have failed to demonstrate clinically relevant effects on the hypothalamic-pituitary-adrenal axis in children and adults at recommended doses. 4, 3
• Long-term use does not affect systemic cortisol levels or increase risk of lens opacity, elevated intraocular pressure, or glaucoma. 4
• Periodically examine the nasal septum during long-term use to detect mucosal erosions that may precede septal perforation (a rare complication). 4

When Initial Treatment Fails

If symptoms persist after 2 weeks of fluticasone monotherapy, add intranasal azelastine (an intranasal antihistamine). 2 The combination of fluticasone propionate and azelastine provides more than 40% greater symptom reduction than either agent alone. 4, 2

• If no improvement occurs after 3 months of intranasal corticosteroid therapy, consider a short course of oral corticosteroids or proceed to CT imaging and surgical evaluation. 4
• Oral antihistamines are less effective than intranasal corticosteroids for nasal congestion, though they may help with sneezing and itching. 4
• Leukotriene receptor antagonists are not recommended as primary therapy, as they are significantly less effective than intranasal corticosteroids. 4

Contraindications

Fluticasone is contraindicated in patients with hypersensitivity to fluticasone or any component of the formulation. 4, 2