What is the recommended dose of Flonase (fluticasone propionate) for a typical adult patient with allergic rhinitis?

Flonase (Fluticasone Propionate) Dosing for Allergic Rhinitis

For adults and adolescents ≥12 years: Start with 2 sprays (50 mcg each) in each nostril once daily (total 200 mcg/day), which can be reduced to 1 spray per nostril once daily for maintenance after the first few days. 1

Adult Dosing (≥12 years)

The FDA-approved starting dose is 200 mcg once daily (2 sprays per nostril), administered either as a single morning dose or divided into 100 mcg twice daily (1 spray per nostril at 8 AM and 8 PM). 1 Both regimens are equally effective, with no significant differences demonstrated in six clinical trials. 1

• After the first few days of treatment, many patients can reduce to a maintenance dose of 100 mcg once daily (1 spray per nostril). 1
• For seasonal allergic rhinitis specifically, some adults may use 200 mcg once daily on an "as-needed" basis for symptom control, though scheduled regular use achieves greater symptom control. 1
• The maximum dose should not exceed 2 sprays per nostril daily (200 mcg total). 1

Pediatric Dosing (Ages 4-11 years)

Children should start with 100 mcg once daily (1 spray per nostril). 1 This lower dose is as effective as the 200 mcg adult dose in pediatric patients and does not interfere with the hypothalamic-pituitary-adrenal axis. 2

• If inadequate response occurs, the dose may be increased to 200 mcg once daily (2 sprays per nostril). 1
• Once adequate control is achieved, decrease back to 100 mcg daily for maintenance. 1
• Maximum dose should not exceed 2 sprays per nostril (200 mcg/day). 1
• Fluticasone is not recommended for children under 4 years of age. 1

Onset of Action and Expectations

Symptom relief begins within 12 hours of the first dose, with some patients experiencing benefit as early as 3-4 hours, though maximum effect requires days to weeks of regular use. 3, 4, 1 In controlled trials, a decrease in nasal symptoms compared to placebo was demonstrated as soon as 12 hours after the initial 200 mcg dose. 1

• Improvement in nasal obstruction, rhinorrhea, sneezing, and itching is evident within 3 days and continues throughout treatment. 5, 6
• Patients must be counseled to continue therapy for at least 2 weeks, as full benefit may not be evident during this initial period. 3

Administration Technique (Critical for Safety)

Direct the spray away from the nasal septum using the contralateral hand technique (right hand for left nostril, left hand for right nostril) to reduce epistaxis risk by four-fold. 3, 4

Additional technique points include:

• Prime the bottle before first use and shake before each administration. 3
• Have the patient blow their nose prior to spraying. 3
• Keep the head upright during administration. 3
• Breathe in gently during spraying without closing the opposite nostril. 3

Long-Term Use and Safety

Fluticasone can be used indefinitely for perennial allergic rhinitis, as long-term studies up to 6 months demonstrate no suppression of the hypothalamic-pituitary-adrenal axis, no growth effects in children at recommended doses, and no evidence of nasal mucosal atrophy. 3, 2, 7

• The most common adverse effect is epistaxis (blood-tinged nasal secretions), occurring in 5-10% of patients, which is typically mild and manageable with proper technique. 3
• Periodically examine the nasal septum every 6-12 months during long-term use to detect mucosal erosions that may precede septal perforation (a rare complication). 3
• Studies in children show no effect on growth at recommended doses, even at up to twice the recommended doses. 3, 2

When to Escalate or Modify Therapy

If symptoms persist after 2 weeks of regular fluticasone use, add an intranasal antihistamine (azelastine) rather than increasing the fluticasone dose, as combination therapy provides >40% greater symptom reduction than fluticasone alone. 3, 4

• There is no evidence that exceeding 200 mcg/day is more effective. 1
• For severe nasal congestion preventing spray penetration, consider a topical decongestant for 3-5 days maximum while initiating fluticasone. 3

Common Pitfalls to Avoid

• Do not use fluticasone "as needed" like a decongestant—it is maintenance therapy requiring regular daily use for optimal effect. 3
• Do not aim the spray directly at the nasal septum—this dramatically increases epistaxis risk. 3, 4
• Do not discontinue when symptoms improve—perennial allergic rhinitis requires continuous treatment due to ongoing allergen exposure. 3
• Do not delay initiation waiting for allergy testing—start treatment immediately upon clinical diagnosis when symptoms affect quality of life. 3