Can Flonase (fluticasone) be ordered for a patient with fluid overload who is experiencing nasal congestion?

From the Guidelines

You can order Flonase (fluticasone propionate) for a patient with fluid overload who is experiencing nasal congestion, but it is crucial to first address the underlying fluid overload with diuretics or other treatments targeting volume status, as this may resolve the nasal congestion without requiring additional medication. The standard dosing of Flonase is 1-2 sprays in each nostril once daily. However, it's essential to consider that the patient's nasal congestion may be directly related to their fluid overload rather than allergic rhinitis, which is what Flonase primarily treats. Flonase works by reducing inflammation in the nasal passages through corticosteroid action, but it may not address the underlying cause of congestion in this case. Some key points to consider when managing a patient with fluid overload and nasal congestion include:

• Addressing the fluid overload with diuretics or other treatments targeting volume status, as recommended by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1
• Monitoring the patient's fluid status, perfusion, and systemic or pulmonary vascular resistances, as suggested by the 2009 ACCF/AHA guidelines for the diagnosis and management of heart failure in adults 1
• Considering the use of vasodilators, such as intravenous nitroglycerin or nesiritide, in patients with evidence of severely symptomatic fluid overload, as recommended by the 2009 focused update incorporated into the ACC/aha 2005 guidelines for the diagnosis and management of heart failure in adults 1
• Being cautious when initiating beta-blocker therapy in patients with fluid overload, as recommended by the 2013 ACCF/AHA guideline for the management of heart failure 1 It's also important to note that the patient's congestion might be better managed by addressing the excess fluid with diuretics or other treatments targeting their volume status, rather than solely relying on Flonase. While Flonase is generally safe with minimal systemic absorption, ensuring the patient's fluid status is being adequately addressed is crucial, as this may resolve the nasal congestion without requiring additional medication.

From the FDA Drug Label

Patients using Fluticasone Propionate Nasal Spray, USP, over several months or longer should be examined periodically for evidence of Candida infection or other signs of adverse effects on the nasal mucosa Because of the inhibitory effect of corticosteroids on wound healing, patients who have experienced recent nasal septal ulcers, nasal surgery, or nasal trauma should not use a nasal corticosteroid until healing has occurred. Nasal mucosal basophils and eosinophils were also reduced at the end of treatment in adult studies; however, the clinical significance of this decrease is not known

The patient is here for fluid overload and is asking for nasal spray for congestion. Flonase (fluticasone) can be used for congestion, but it is a corticosteroid and should be used with caution.

• The patient's fluid overload status does not directly relate to the use of Flonase.
• There is no information in the provided drug labels that would prevent the use of Flonase for congestion in a patient with fluid overload.
• However, it is essential to consider the potential risks and benefits of using a corticosteroid nasal spray, especially if the patient has any underlying conditions or is taking other medications.
• The patient should be monitored for any signs of adverse effects, such as Candida infection or impaired wound healing.
• It is recommended to start with a low dose and titrate as needed to minimize systemic effects. 2

From the Research

Nasal Congestion Treatment

• The patient is experiencing fluid overload and is asking for a nasal spray for congestion, specifically inquiring about Flonase.
• Flonase is a brand name for fluticasone, a nasal steroid spray used to treat nasal congestion associated with allergies or other conditions.

Efficacy of Flonase

• A study published in 2021 3 found that the exhalation delivery system with fluticasone was effective in improving symptoms of nasal congestion, rhinorrhea, and facial pain/pressure in patients with chronic rhinosinusitis who remained symptomatic despite using standard nasal steroid sprays.
• However, another study published in 2021 4 compared the efficacy of loratadine-pseudoephedrine and fluticasone nasal spray for allergic rhinitis and found that a single dose of loratadine-pseudoephedrine resulted in a significantly greater improvement in nasal airflow compared to fluticasone nasal spray.

Alternative Decongestants

• Pseudoephedrine is a commonly used oral decongestant that has been shown to be effective in reducing nasal congestion associated with the common cold or allergies 5, 4.
• However, the use of pseudoephedrine and other vasoconstrictors should be carefully considered in patients with certain medical conditions, such as hypertension or cardiovascular disease, due to the risk of adverse effects 6.

Safety Considerations

• A study published in 2015 7 found that phenylephrine, another common decongestant, was not significantly more effective than placebo in relieving nasal congestion in adults with seasonal allergic rhinitis.
• The same study also found that phenylephrine was well-tolerated at doses of up to 30 mg, but the use of vasoconstrictors like phenylephrine and pseudoephedrine should be carefully monitored due to the risk of adverse effects 6.