Are there any issues with using fluticasone (Flonase) in a patient with a known Arteriovenous Malformation (AVM)?

Fluticasone Use in Patients with Known AVM

Fluticasone (intranasal corticosteroid) can be safely used in patients with known arteriovenous malformations, as there is no established contraindication or increased hemorrhage risk associated with topical nasal corticosteroids in this population.

Key Clinical Considerations

No Direct Contraindication Exists

• The available AVM management guidelines from the American Stroke Association do not identify intranasal corticosteroids as a risk factor for AVM hemorrhage or progression 1.
• Hemorrhage risk in AVMs is primarily determined by lesion-specific factors including prior hemorrhage history, AVM size, location, and angioarchitecture—not by use of topical nasal medications 1.

Understanding AVM Hemorrhage Risk Factors

The baseline annual hemorrhage risk for unruptured AVMs is 2-4% per year, which is determined by:

• Prior hemorrhage status: Risk increases to 6-18% in the first year after initial bleed, and up to 25% after a second hemorrhage 2.
• AVM size and location: Smaller AVMs and those in deep/eloquent locations may carry higher rupture risk 1.
• Venous drainage patterns and feeding vessel characteristics: Complex angioarchitecture identified on angiography affects risk 1.

Systemic vs. Topical Corticosteroid Considerations

• Fluticasone is a topical intranasal corticosteroid with minimal systemic absorption when used at recommended doses.
• The AVM literature does not identify systemic corticosteroids as contraindicated, though blood pressure control is emphasized during perioperative management 1.
• No evidence suggests topical nasal corticosteroids affect vascular integrity or increase bleeding risk in cerebral or other AVMs 1.

Important Caveats

Distinguish AVM Type

• Cerebral AVMs (intracranial) have different natural history than peripheral AVMs, but neither type has documented interactions with intranasal corticosteroids 3, 2.
• Venous malformations are distinct from AVMs and have extremely low hemorrhage risk; fluticasone poses no concern in these patients 3.

Hereditary Hemorrhagic Telangiectasia (HHT) Consideration

• If the patient has HHT (a genetic syndrome causing multiple AVMs and telangiectasias), epistaxis is a major concern 1, 4.
• In HHT patients, intranasal corticosteroids are not contraindicated but should be used cautiously as nasal mucosal drying could theoretically worsen epistaxis.
• Medical therapies for HHT-related bleeding include bevacizumab and thalidomide, not avoidance of topical steroids 1.

Clinical Recommendation Algorithm

For patients with known AVM considering fluticasone:

1. Confirm AVM type and location (cerebral vs. peripheral, venous malformation vs. true AVM) 3, 2.
2. Assess for HHT if multiple vascular lesions or family history present 1, 4.
3. Proceed with fluticasone for standard indications (allergic rhinitis, chronic rhinosinusitis) without specific AVM-related restrictions 1.
4. Monitor for epistaxis in all patients, particularly those with HHT or nasal/facial AVMs.
5. Maintain blood pressure control as part of overall AVM management, regardless of fluticasone use 1, 2.

Common Pitfall to Avoid

• Do not confuse systemic anticoagulation concerns with topical corticosteroid use—while anticoagulation requires careful consideration in AVM patients, topical nasal steroids do not have similar bleeding implications 1.