What is the recommended treatment plan for a 16-year-old female patient with a history of allergic rhinitis, who has been using Fluticasone propionate (Flonase) nasal spray for 6 months out of the year and has run out of her prescription?

Prescription for Fluticasone Propionate Nasal Spray Refill

For this 16-year-old patient with well-controlled seasonal allergic rhinitis using fluticasone propionate nasal spray for 6 months per year, prescribe fluticasone propionate (Flonase) 50 mcg/spray nasal spray, 2 sprays per nostril once daily, with a quantity sufficient for her seasonal use pattern. 1, 2

Prescription Details

Medication: Fluticasone propionate (Flonase) aqueous nasal spray 50 mcg/spray

Dosing for age ≥12 years:

• Standard dose: 2 sprays in each nostril once daily (200 mcg total daily dose) 1, 2
• Timing: Once daily in the morning for optimal compliance 3
• Duration: Continue throughout allergen exposure season, up to 6 months per year without requiring physician follow-up 4

Quantity to dispense:

• For 6 months of daily use: Dispense 3-4 bottles of 120 sprays each (accounting for priming) 4
• Each 120-spray bottle provides approximately 1 month of therapy at 2 sprays per nostril daily 4

Refills: 0-1 refills (patient should follow up if needing continuous use beyond 6 months) 4

Critical Administration Instructions

Proper technique is essential to maximize efficacy and minimize epistaxis risk:

• Use contralateral hand technique (right hand for left nostril, left hand for right nostril) - this reduces epistaxis risk by 4-fold 2, 5
• Prime the bottle before first use and after periods of non-use 5
• Shake bottle before each use 5
• Blow nose before administering 5
• Keep head upright during administration 5
• Breathe in gently during spray (like smelling a flower) 5, 4
• Do NOT close the opposite nostril during administration 5
• Direct spray away from nasal septum 1, 2

Expected Timeline and Patient Counseling

Onset of action:

• Initial symptom relief may begin within 12-24 hours 5, 4, 6
• Maximum therapeutic effect requires several days to weeks of regular daily use 2, 5, 4
• Improvement in nasal obstruction evident within 3 days 6, 7

Key counseling points:

• Continue daily use throughout allergen exposure season even when symptoms improve - this is maintenance therapy, not rescue therapy 4
• Does NOT cause rebound congestion (unlike topical decongestants) 1, 4
• Does NOT cause drowsiness 4
• Does NOT increase blood pressure 4
• Safe for long-term seasonal use up to 6 months per year at age ≥12 years 4

Common Side Effects and When to Stop

Expected mild side effects (generally well-tolerated):

• Headache, pharyngitis, epistaxis (blood-tinged mucus), nasal burning/irritation 2, 5, 4
• Minor nosebleeds or nasal dryness 4, 8
• Bad taste or smell 4

Stop use and contact physician if:

• Severe or frequent nosebleeds occur 4
• Constant whistling sound from nose (suggests septal damage) 4
• Severe facial/sinus pain or thick nasal discharge (suggests infection) 4
• No improvement after 1 week of regular use 4
• Sudden swelling of face/tongue, rash, wheezing, or feeling faint (allergic reaction) 4

Safety Considerations for This Patient

No laboratory monitoring required:

• No clinically significant HPA axis suppression at recommended doses 1, 6, 3, 8
• No growth effects at recommended doses in adolescents 1
• Minimal systemic absorption 8

Drug interactions to verify:

• Confirm patient is NOT taking ritonavir (HIV medication) or ketoconazole pills 4
• Confirm patient is NOT using other steroid medications concurrently 4

Contraindications:

• History of hypersensitivity to fluticasone propionate or its components 2, 5, 4

When to Follow Up

• If symptoms not controlled after 1 week of regular use - may need evaluation for infection or alternative diagnosis 4
• If requiring continuous daily use beyond 6 months - should check with physician to ensure ongoing appropriateness 4
• If needing higher doses (e.g., 2 sprays per nostril twice daily for severe congestion) - should be temporary with plan to reduce to maintenance dosing 1

Alternative Options if Current Therapy Fails

If inadequate response to fluticasone alone:

• Consider adding intranasal azelastine (antihistamine) for combination therapy - shows >40% relative improvement over monotherapy 1, 2

If fluticasone not tolerated:

• Alternative intranasal corticosteroids: mometasone furoate or triamcinolone acetonide 1