Can I prescribe Flonase (fluticasone propionate) and a steroid pack to a patient presenting with cough, post nasal drip, nasal congestion, and itchy throat, suggestive of allergic rhinitis?

Treatment Recommendation for Allergic Rhinitis

Prescribe Flonase (fluticasone propionate nasal spray) alone without a systemic steroid pack for this patient with symptoms of allergic rhinitis. 1

Why Flonase Alone is the Correct Choice

Intranasal corticosteroids like Flonase are the most effective medication class for controlling all symptoms of allergic rhinitis, including cough, post-nasal drip, nasal congestion, and itchy throat. 1, 2 The evidence consistently demonstrates that intranasal corticosteroids are superior to oral antihistamines, leukotriene antagonists, and combination therapy for these symptoms. 1, 2

Specific Dosing Instructions

For adults and adolescents ≥12 years:

• Start with 2 sprays in each nostril once daily (200 mcg total daily dose) 3, 4
• Can be divided into twice-daily dosing if needed for severe symptoms 3
• Once symptoms are controlled, may reduce to 1 spray per nostril daily for maintenance 4

For children ages 4-11 years:

• Use 1 spray in each nostril once daily (100 mcg total daily dose) 4
• Do not exceed 2 months of continuous use per year without physician follow-up 4

Why NOT to Prescribe a Systemic Steroid Pack

Oral corticosteroids are contraindicated for routine allergic rhinitis and should only be considered for rare patients with severe intractable symptoms unresponsive to all other treatments, and only as short 5-7 day courses. 3 The rationale for avoiding systemic steroids includes:

• No mortality or morbidity benefit: Allergic rhinitis does not cause life-threatening complications that require systemic steroids 1
• Unnecessary systemic side effects: Oral steroids carry risks of adrenal suppression, hyperglycemia, mood changes, and other systemic effects that intranasal steroids avoid 1, 3
• Intranasal steroids are equally or more effective: Studies show intranasal corticosteroids provide superior symptom control compared to systemic approaches for nasal symptoms 1, 5

Timeline for Symptom Relief

Counsel the patient that symptom improvement begins within 3-12 hours, but maximum benefit may take several days to weeks of regular use. 1, 6, 2 This is critical patient education to prevent premature discontinuation. The patient must understand that Flonase is maintenance therapy, not rescue therapy, and should be used daily throughout allergen exposure. 4

Proper Administration Technique

Teach the patient to use the contralateral hand technique (right hand for left nostril, left hand for right nostril) to direct the spray away from the nasal septum. 3 This reduces epistaxis risk by four times. 3 Additional technique points include:

• Prime the bottle before first use 4
• Shake the bottle prior to each use 3
• Keep head upright during administration 3
• Breathe in gently during spraying 3
• Do not close the opposite nostril 3

When to Consider Adding Therapy

If symptoms are not adequately controlled after 2 weeks of regular Flonase use, consider adding an oral antihistamine like loratadine 10 mg once daily or cetirizine. 1, 6 Approximately 50% of patients with seasonal allergic rhinitis require both intranasal corticosteroids and oral antihistamines for adequate symptom control. 1, 6 The combination of fluticasone propionate and loratadine has shown superior efficacy for some patient-rated symptoms compared to fluticasone alone. 1, 6

Safety Profile and Long-Term Use

Flonase has an excellent safety profile with no clinically significant effects on the hypothalamic-pituitary-adrenal axis, growth (at recommended doses), or bone density. 3, 2 Common side effects are limited to:

• Epistaxis (blood-tinged nasal secretions) in 5-10% of patients 1, 5
• Nasal dryness or burning 4, 5
• Headache 4, 5
• Pharyngitis 3

For adults using daily for longer than 6 months, schedule a follow-up visit to assess continued need and examine the nasal septum for mucosal erosions. 3, 4

Common Pitfalls to Avoid

• Do not prescribe systemic steroids for uncomplicated allergic rhinitis - this exposes patients to unnecessary systemic risks without additional benefit 3
• Do not allow patients to use Flonase "as needed" - while some efficacy exists with PRN dosing, continuous daily use is more effective 1
• Do not add a nasal decongestant spray for more than 3 days - this causes rebound congestion (rhinitis medicamentosa), whereas intranasal corticosteroids are safe for long-term use 3
• Do not assume lack of immediate relief means treatment failure - patients need to continue for at least 2 weeks to properly assess benefit 3