What is the recommended treatment for a patient with allergic rhinitis using Flonase (fluticasone propionate)?

Fluticasone Propionate (Flonase) for Allergic Rhinitis

Fluticasone propionate nasal spray is the most effective first-line treatment for allergic rhinitis, used at 2 sprays per nostril once daily (200 mcg total) for adults and adolescents ≥12 years, or 1 spray per nostril once daily for children 4-11 years, continued regularly throughout allergen exposure rather than as-needed. 1, 2

Age-Specific Dosing

Adults and Adolescents ≥12 Years

• Start with 2 sprays per nostril once daily (200 mcg total daily dose) 1, 3
• For severe nasal congestion unresponsive to standard dosing, may temporarily increase to 2 sprays per nostril twice daily (400 mcg/day), then reduce to maintenance dosing once symptoms are controlled 1, 2
• Maximum duration before physician consultation: 6 months of daily use 3

Children 4-11 Years

• Use 1 spray per nostril once daily (100 mcg total daily dose) 1, 3
• Maximum duration before physician consultation: 2 months per year 3
• This age restriction exists because long-term intranasal corticosteroids may slow growth rate in some children, though fluticasone propionate at recommended doses shows no effect on growth compared to placebo 1, 3

Not Approved for Children <4 Years

• Fluticasone propionate is FDA-approved only for children ≥4 years 1
• For younger children (2-3 years), consider mometasone furoate or triamcinolone acetonide instead 1

Critical Administration Technique

Proper technique is essential—improper use reduces efficacy and increases side effects by 4-fold. 1, 2

Step-by-Step Technique

• Prime the bottle before first use by shaking and spraying until mist appears 1
• Shake the bottle before each use 1
• Have patient blow nose prior to spraying 1
• Use contralateral hand technique: hold spray in opposite hand relative to the nostril being treated (this reduces epistaxis risk by 4 times) 1, 2
• Keep head upright during administration 1, 2
• Direct spray away from nasal septum toward outer nasal wall 1
• Breathe in gently during spraying 1, 2
• Do not close the opposite nostril during administration 1, 2
• If using nasal saline irrigations, perform them before administering fluticasone to avoid rinsing out the medication 1

Timing and Expectations

Onset of Action

• Initial symptom improvement begins within 12 hours to 3 days 1, 4, 5
• Maximum therapeutic effect requires several days to weeks of regular use 1, 2
• This delayed onset occurs because fluticasone acts on multiple inflammatory mediators (histamine, prostaglandins, cytokines, leukotrienes), not just histamine like oral antihistamines 3

Maintenance Therapy

• Use regularly and continuously throughout allergen exposure, not as-needed 1, 2, 3
• Continue daily use even when symptoms improve to maintain relief 1, 3
• For seasonal allergies, start before symptom onset and continue throughout the allergen season 1
• For perennial allergies, continuous year-round therapy is appropriate and safe 1, 6

Long-Term Safety Profile

Fluticasone propionate is safe for extended use with no systemic effects at recommended doses. 1, 7

Systemic Safety

• No suppression of hypothalamic-pituitary-adrenal axis at recommended doses in children or adults 1, 2, 4, 7, 5
• No effect on growth at recommended doses (even up to twice recommended doses) in pediatric studies 1
• Minimal systemic absorption—efficacy results from direct topical effects in the nose 8, 7
• No increased risk of lens opacity, elevated intraocular pressure, or glaucoma with prolonged use 1
• Nasal mucosa biopsies after 1-5 years of continuous use show no evidence of atrophy 1

Local Side Effects

• Most common: epistaxis (nasal bleeding), typically blood-tinged secretions 1, 2, 3
• Other common effects: headache, pharyngitis, nasal burning/irritation, nausea, cough 1, 2, 3
• Nasal septal perforation is rare and preventable with proper contralateral spray technique 1
• All side effects are generally mild to moderate 1, 4, 6

Monitoring Requirements

• Periodically examine nasal septum (every 6-12 months during long-term use) to detect mucosal erosions that may precede perforation 1
• No routine laboratory monitoring required 4, 5

When Initial Treatment Fails

Add Intranasal Antihistamine

• For moderate-to-severe allergic rhinitis inadequately controlled on fluticasone alone, add intranasal azelastine 2, 9
• The combination of fluticasone plus azelastine provides 40% greater symptom reduction compared to either agent alone 9
• Combination therapy is particularly effective for patients with ocular symptoms 9
• Common side effect of azelastine: dysgeusia (altered taste) 9

Reassessment Timeline

• If no improvement after 3 months of intranasal corticosteroid therapy, consider short course of oral corticosteroids or proceed to CT imaging and surgical evaluation 1

Important Contraindications and Cautions

Do Not Use If:

• History of hypersensitivity to fluticasone propionate or any component 1, 2, 3
• Taking ritonavir (HIV medication) or ketoconazole pills—consult physician first 3
• Currently using other steroid medications (for asthma, skin conditions, etc.)—consult physician first 3

Not Indicated For:

• Asthma treatment (fluticasone nasal spray does not treat asthma) 3
• Cold symptoms (use only for allergies, not colds) 3

Common Pitfalls to Avoid

• Discontinuing therapy when symptoms improve: Continue regular use throughout allergen exposure to maintain relief 1, 3
• Using as rescue therapy: Fluticasone is maintenance therapy, not a quick-relief medication like decongestants 1
• Improper spray technique: Ipsilateral technique (same hand as nostril) increases epistaxis risk 4-fold 1, 2
• Expecting immediate relief: Full benefit requires days to weeks of regular use 1, 2
• Confusing with topical decongestants: Unlike decongestants (limited to 3 days), fluticasone does not cause rebound congestion and is safe for long-term daily use 1

Comparison to Other Intranasal Corticosteroids

• Fluticasone propionate once daily is as effective as twice-daily dosing 6, 5
• Fluticasone propionate once daily is as effective as beclomethasone dipropionate twice daily 6
• All intranasal corticosteroids are more effective than oral antihistamines for controlling all four major symptoms of allergic rhinitis 1
• Intranasal corticosteroids are more effective than leukotriene receptor antagonists 1