What is the preferred nasal spray, Fluticasone (Flonase) vs Mometasone, for a patient with allergic rhinitis?

Fluticasone vs Mometasone for Allergic Rhinitis

Both fluticasone propionate and mometasone furoate are equally effective intranasal corticosteroids for allergic rhinitis, with no clinically meaningful differences in efficacy or safety—choose based on age-appropriateness, cost, and patient preference. 1

Efficacy Comparison

The clinical response does not vary significantly between fluticasone propionate and mometasone furoate for treating allergic rhinitis. 1 Both medications effectively control all four major nasal symptoms: sneezing, itching, rhinorrhea, and nasal congestion. 1

• Onset of action: Both medications provide symptom relief within 3-12 hours after administration, with fluticasone showing benefit as early as 8 hours. 1, 2
• Symptom control: Mometasone furoate 200 mcg once daily demonstrates onset of action at approximately 7 hours in seasonal allergic rhinitis. 3
• Comparative trials: Mometasone furoate was as effective as once-daily fluticasone propionate in treating perennial allergic rhinitis. 3

Age-Specific Recommendations

For children aged 2-3 years: Mometasone furoate is the preferred choice, as it is FDA-approved for children ≥2 years at 1 spray per nostril daily (100 mcg total). 4, 5

For children aged 4-11 years: Either medication is appropriate. Fluticasone propionate is dosed at 1 spray per nostril daily (50 mcg per spray), while mometasone furoate uses the same dosing. 4, 6

For adolescents ≥12 years and adults: Both medications are dosed at 2 sprays per nostril once daily (fluticasone 200 mcg total; mometasone 200 mcg total). 4, 6

Safety Profile

Both medications demonstrate excellent safety profiles with no clinically significant differences. 1

• Growth effects: Studies with both fluticasone propionate and mometasone furoate show no effect on growth at recommended doses compared to placebo, even at up to twice the recommended doses. 6, 1
• HPA axis suppression: Neither medication demonstrates clinically significant effects on hypothalamic-pituitary-adrenal axis function at recommended doses. 1, 3
• Ocular effects: Neither medication shows increased risk of elevated intraocular pressure, glaucoma, or cataract formation. 1
• Long-term use: Nasal biopsies from patients treated continuously for 1-5 years show no evidence of atrophy with either medication. 6

Common Side Effects

The adverse event profiles are nearly identical for both medications. 4

Fluticasone propionate: Headache, pharyngitis, epistaxis, nasal burning/irritation, nausea, vomiting, asthma symptoms, and cough. 4, 6

Mometasone furoate: Headache, viral infection, pharyngitis, epistaxis, and cough. 4, 6

• Epistaxis management: Direct the spray away from the nasal septum using contralateral hand technique, which reduces epistaxis risk by four times. 6
• Frequency: Epistaxis typically presents as blood-tinged secretions rather than severe nosebleeds, occurring in 5-10% of patients. 6

Dosing Considerations

Standard dosing for both medications provides equivalent efficacy when used once daily. 7, 3

For severe congestion: Consider starting with 2 sprays per nostril twice daily (400 mcg/day total) for mometasone in adults, particularly for nasal polyps, then reducing to maintenance dosing once symptoms are controlled. 6

Continuous vs. as-needed: Regular daily use throughout the allergen exposure season is more effective than intermittent use for both medications. 1

Clinical Decision Algorithm

1. Age < 4 years: Use mometasone furoate (FDA-approved for ≥2 years). 4, 5
2. Age ≥ 4 years: Either medication is appropriate—choose based on cost and availability. 1
3. Severe nasal congestion: Consider mometasone 200 mcg twice daily initially, then reduce to once daily. 6
4. Cost considerations: Fluticasone propionate is available over-the-counter and in generic form, potentially reducing cost. 4

Important Caveats

• Minimum treatment duration: Continue therapy for at least 2 weeks to assess full benefit, as maximal efficacy requires days to weeks of regular use. 6, 1
• Proper technique: Teach contralateral hand technique (use right hand for left nostril, left hand for right nostril) to minimize epistaxis risk. 6
• Monitoring: Periodically examine the nasal septum every 6-12 months during long-term use to detect mucosal erosions that may precede septal perforation. 6
• Contraindications: Both medications are contraindicated in patients with hypersensitivity to the medication or its components. 4, 6

When to Add Additional Therapy

If monotherapy with either intranasal corticosteroid provides inadequate symptom control after 2-4 weeks, add an intranasal antihistamine (azelastine) rather than an oral antihistamine, as combination intranasal therapy (fluticasone + azelastine) provides >40% relative improvement compared to either agent alone. 4