What are the contraindications for Flonase (fluticasone propionate) in patients with various medical conditions, including glaucoma, cataracts, nasal trauma, or surgery, and in pediatric patients?

Contraindications to Flonase (Fluticasone Propionate Nasal Spray)

The only absolute contraindication to Flonase is hypersensitivity to fluticasone propionate or any ingredient in the formulation. 1

Absolute Contraindications

• Known hypersensitivity or allergic reaction to fluticasone propionate or any component of the product 1
• Unhealed nasal trauma or recent nasal surgery until complete healing has occurred 1

Situations Requiring Medical Consultation Before Use

Ocular Conditions

• Glaucoma or cataracts (current or history): While standard doses of intranasal fluticasone propionate do not increase risk for glaucoma or cataracts based on prospective 24-week studies, patients with pre-existing ocular conditions should consult a physician before use 2, 3
• Studies specifically evaluating fluticasone propionate irrigations at 3 mg twice daily (substantially higher than standard nasal spray doses) found no changes in intraocular pressure or development of posterior subcapsular cataracts after 6 weeks 3
• Individual patient variability may allow for ocular effects, especially in older patients, despite overall safety data 2

Drug Interactions Requiring Caution

• HIV protease inhibitors (particularly ritonavir): Potent CYP3A4 inhibitors can increase systemic fluticasone concentrations, potentially causing Cushing syndrome and adrenal suppression 2, 1
• Ketoconazole: Another potent CYP3A4 inhibitor that increases oral availability and decreases systemic clearance of fluticasone 2, 1
• Concurrent systemic corticosteroids or other inhaled/intranasal corticosteroids: Increases risk of systemic effects including adrenal suppression 2

Pediatric Considerations

• Children under 4 years of age: Not approved for use in this age group 1
• Children 4-11 years: Can use for up to 2 months per year; longer duration requires physician consultation due to potential growth velocity suppression 2, 1
• Growth suppression has been observed in children on low-to-medium doses, though effects may be transient 2

Active Infections

• Untreated nasal infections: Severe sinus pain with thick nasal discharge suggests bacterial sinusitis requiring physician evaluation 1
• Tuberculosis (active or latent): Stop use and consult physician 1
• Chickenpox or measles (active infection or recent exposure): Discontinue fluticasone and seek medical advice 1

Important Clinical Caveats

Not True Contraindications But Require Monitoring

• Nasal septal abnormalities: Direct spray away from septum to prevent repetitive trauma that may lead to septal perforation, though this is rare 2
• The nasal septum should be examined periodically for mucosal erosions, which may precede perforation 2

Pregnancy and Lactation

• No specific contraindication listed in FDA labeling, but all medications should be used with caution 1

Common Pitfalls to Avoid

• Do not confuse with rebound rhinitis medications: Fluticasone propionate does not cause rebound congestion like decongestant nasal sprays and can be used for up to 6 months in patients ≥12 years 1
• Do not share bottles: This spreads infectious organisms 1
• Do not assume OTC availability means no risks: Pharmacist consultation ensures proper technique and screening for contraindications 4

When to Stop and Seek Medical Attention

• Severe or frequent nosebleeds: Apply pressure, discontinue use, and see physician 1
• Constant whistling sound from nose: May indicate nasal damage; stop immediately and seek evaluation 1
• Sudden facial/tongue swelling, rash, wheezing, or feeling faint: Signs of allergic reaction requiring immediate medical attention 1
• No improvement after 1 week of use: May indicate infection or incorrect diagnosis 1