Can a Patient with Glaucoma Take Flonase?
Yes, patients with glaucoma can safely use Flonase (fluticasone propionate nasal spray), as intranasal corticosteroids at recommended doses do not increase the risk of glaucoma or elevated intraocular pressure. 1
Evidence Supporting Safety in Glaucoma Patients
The most definitive evidence comes from prospective studies showing that intranasal corticosteroids, including fluticasone propionate, do not pose a risk for glaucoma development:
Patients receiving standard doses of intranasal corticosteroids are not at increased risk for the development of glaucoma. 1
Long-term use of intranasal steroids has not been shown to increase the risk of elevated intraocular pressure or any other ocular symptoms. 1
Studies of intranasal corticosteroids in prospective trials of 24 weeks have not demonstrated the development of lenticular changes consistent with posterior subcapsular cataracts. 1
Critical Distinction: Route of Administration Matters
The key to understanding this safety profile is recognizing that the route of corticosteroid administration dramatically affects glaucoma risk:
Topical ocular corticosteroids (eye drops) pose a real danger to patients with open-angle glaucoma, as they can cause vision loss that is gradual, insidious, and irreversible. 2
Chronic use of corticosteroids, especially as eye drops, can cause elevated intraocular pressure through increased aqueous outflow resistance due to accumulation of extracellular matrix material in the trabecular meshwork. 3
In contrast, intranasal corticosteroids have minimal systemic absorption and do not achieve the ocular tissue concentrations necessary to affect intraocular pressure. 1, 4
Rare Instances and Individual Variability
While the evidence strongly supports safety, the FDA label acknowledges extremely rare occurrences:
Rare instances of glaucoma and increased intraocular pressure have been reported following intranasal application of corticosteroids, including fluticasone propionate. 5
Individual patient variability may allow for the development of ocular effects from intranasal corticosteroids, especially in older patients. 1
Corticosteroid responsiveness varies between individuals, with the most important risk factor being personal or family history of primary open-angle glaucoma. 6
Monitoring Recommendations
For patients with pre-existing glaucoma using intranasal corticosteroids long-term, consider the following approach:
Patients on long-term topical nasal steroids should consult their physicians to determine if regular ophthalmic monitoring is appropriate. 1
This is a discretionary recommendation based on theoretical risk rather than demonstrated harm in clinical trials. 1
No routine monitoring is required for short-term use (less than 12 weeks). 4
Common Pitfall to Avoid
Do not confuse the contraindication for topical ocular corticosteroids with the safety profile of intranasal corticosteroids. The package insert warning about glaucoma that appears on many medications can be misleading when it comes to intranasal steroids. 2 The chronic use of corticosteroid eye drops is what poses genuine risk to glaucoma patients, not nasal sprays. 2
Proper Administration to Maximize Safety
To minimize any theoretical systemic absorption: