What is the recommended dosing of Flovent (fluticasone propionate) for pediatric patients with asthma?

Flovent Dosing for Pediatric Asthma

For children with persistent asthma, start with low-dose fluticasone propionate (100-200 mcg/day total) administered twice daily via metered-dose inhaler with spacer, titrating to the minimum effective dose that maintains control. 1, 2

Age-Specific Dosing Recommendations

Children 4-11 Years Old

• Low dose: 100-200 mcg/day total (e.g., 50-100 mcg twice daily) 2
• Medium dose: >200-500 mcg/day for dry powder inhaler (DPI) or >176-352 mcg/day for HFA/MDI 2
• High dose: >500 mcg/day (DPI) or >352 mcg/day (HFA/MDI) 2

Children 0-4 Years Old

• Low dose: ≤176 mcg/day total 2
• Fluticasone DPI is FDA-approved only for children >4 years of age 1
• For children <4 years, use MDI with valved holding chamber and face mask 1

Adolescents ≥12 Years

• Low dose: 100-250 mcg/day total 2
• Medium dose: >250-500 mcg/day 2
• High dose: >500 mcg/day 2

Stepwise Treatment Algorithm

Step 1 (Intermittent Asthma): Short-acting beta-agonist as needed only; no controller therapy required 2

Step 2 (Mild Persistent): Initiate low-dose ICS as preferred controller therapy 1, 2

• Start fluticasone 100 mcg twice daily (200 mcg/day total) 3, 4
• Reassess control every 2-6 weeks 2

Step 3 (Moderate Persistent): Two equivalent options 2

• Option A: Medium-dose ICS monotherapy (preferred for children <5 years due to lack of LABA safety data) 2
• Option B: Low-dose ICS + long-acting beta-agonist (preferred for children ≥5 years) 2, 5

Step 4 (Severe Persistent): Medium-dose ICS + LABA 2

Step 5: High-dose ICS + LABA 2

Step 6: High-dose ICS + LABA + oral corticosteroid 2

Critical Administration Requirements

Always use proper delivery technique: 1, 2

• Children <4 years: MDI with valved holding chamber and face mask that fits snugly over nose and mouth 1
• Children ≥4 years: MDI with spacer or DPI (Diskus) acceptable 1
• Never use fluticasone without a spacer in children <5 years—lung deposition is inadequate 2

Rinse mouth and spit after each use to prevent oral thrush and dysphonia 2

Reassessment and Dose Titration

Initial monitoring: 1, 2

• Reassess asthma control every 2-6 weeks after initiating or adjusting therapy 2
• Discontinue therapy if no clear benefit within 4-6 weeks despite proper technique and adherence 1, 2
• Consider alternative diagnoses if treatment fails 1

Step-down strategy: 1, 2

• After 2-4 months of sustained control, attempt to step down to find minimum effective dose 2
• Children have high rates of spontaneous remission; evaluate need for continued daily therapy after 3 months of control 1

Evidence for Dose Escalation Decisions

When low-dose ICS fails to control asthma in children ≥5 years: 5

• Adding LABA to low-dose ICS is superior to doubling the ICS dose 5
• In a randomized trial of 283 children (ages 4-16), salmeterol 50 mcg + fluticasone 100 mcg twice daily produced 13.7 L/min greater improvement in morning peak flow compared to fluticasone 200 mcg twice daily alone (p<0.001) 5
• Combination therapy resulted in 8.7% more symptom-free days and 8.0% fewer days requiring rescue albuterol 5

For children <5 years with inadequate control on low-dose ICS: 1, 2

• Increase to medium-dose ICS monotherapy (preferred over adding LABA due to limited safety data) 1, 2
• Some data show dose-dependent improvements in exacerbation risk with higher ICS doses in this age group 1

Safety Monitoring

Local effects (common): 2

• Cough, dysphonia, oral thrush (candidiasis) 2
• Prevented by proper spacer use and mouth rinsing 2

Systemic effects (rare at low-medium doses): 2

• Monitor growth velocity in children—transient suppression may occur (~1 cm) but is non-progressive 2
• Morning plasma cortisol and 24-hour urinary cortisol typically unaffected at doses ≤200 mcg/day 6, 4
• Adrenal suppression and bone density effects possible at high doses 2

Common Pitfalls to Avoid

Never continue indefinitely without reassessment—the goal is minimal effective dose, not indefinite therapy 1, 2

Never use LABA as monotherapy—always combine with ICS due to increased risk of severe exacerbations and asthma-related deaths 2

Verify proper technique before escalating dose—most treatment failures result from poor inhaler technique or non-adherence, not inadequate dosing 2

Do not increase to high-dose ICS before considering combination therapy—adding LABA to low-dose ICS provides greater benefit with less risk than high-dose ICS alone 2, 5

Treatment Goals

Successful management achieves: 2

• Minimal or no daytime symptoms and nighttime awakenings 2
• Rescue bronchodilator use ≤2 days/week 2
• No missed school days and full participation in activities 2
• Peak flow >80% predicted with <20% diurnal variability 2
• Prevention of exacerbations requiring oral corticosteroids or emergency care 2