How should I write a prescription for fluticasone propionate nasal spray (Flonase) for allergic rhinitis, including dosing for adults and children aged 2‑11 years?

How to Write a Prescription for Fluticasone Propionate Nasal Spray (Flonase)

Prescription Format

For adults and children ≥12 years, prescribe fluticasone propionate nasal spray 50 mcg/spray with instructions for 2 sprays per nostril once daily (200 mcg total) for the first week, then 1–2 sprays per nostril once daily as needed for symptom control. 1

For children aged 4–11 years, prescribe 1 spray per nostril once daily (100 mcg total). 2, 1

Age-Specific Dosing Details

Adults and Adolescents (≥12 years)

• Week 1: 2 sprays in each nostril once daily (200 mcg total) 1
• Weeks 2 through 6 months: 1 or 2 sprays in each nostril once daily, adjusted based on symptom control 1
• After 6 months of continuous daily use, the patient should consult their physician before continuing 1

Children 4–11 Years

• Dose: 1 spray in each nostril once daily (100 mcg total) 2, 1
• An adult must supervise administration 1
• Important caveat: Growth rate may be slower in some children; use for the shortest duration necessary to achieve symptom relief 1
• If the child requires use for longer than 2 months per year, discuss with the prescribing physician 1

Children 2–3 Years

• Fluticasone propionate is NOT approved for children under 4 years of age 2, 1
• For this age group, consider mometasone furoate or triamcinolone acetonide, which are approved starting at age 2 years 2, 3

Sample Prescription

Rx: Fluticasone propionate nasal spray 50 mcg/spray
Disp: 1 bottle (120 sprays)
Sig (Adults/Children ≥12 years): Shake gently. Prime bottle before first use. Spray 2 sprays in each nostril once daily in the morning for 1 week, then reduce to 1–2 sprays in each nostril once daily as needed.
Sig (Children 4–11 years): Shake gently. Prime bottle before first use. Spray 1 spray in each nostril once daily in the morning. Adult supervision required.
Refills: As appropriate for chronic use

Critical Administration Technique (Must Counsel Patient)

• Prime the bottle before first use by shaking and releasing several test sprays into the air 2
• Shake gently before each use 2, 1
• Blow nose prior to administration 2
• Keep head upright during spraying (not tilted back) 2
• Use contralateral hand technique: Hold the bottle in the opposite hand relative to the nostril being treated (right hand for left nostril, left hand for right nostril) to direct spray away from the nasal septum—this reduces epistaxis risk by four times 2, 3
• Breathe in gently during spraying 2
• Do not close the opposite nostril during administration 2

Setting Expectations for Efficacy

• Symptom relief begins within 12 hours of the first dose, with some patients experiencing benefit as early as 3–4 hours 2
• Maximal efficacy requires days to weeks of continuous daily use 2
• Regular daily use is essential—this is maintenance therapy, not rescue therapy 2
• For patients with predictable seasonal allergies, initiate treatment before symptom onset and continue throughout the allergen exposure period 2

Common Side Effects to Discuss

• Epistaxis (nosebleeds) is the most common side effect, typically presenting as blood-tinged nasal secretions rather than frank bleeding, occurring in 4–8% of patients in short-term use and up to 20% with year-long use 2, 3
• Headache, pharyngitis, nasal burning or irritation 2
• Nausea, vomiting, cough, asthma symptoms (less common) 2
• Proper spray technique minimizes local side effects 2

Safety Reassurance

• No hypothalamic-pituitary-adrenal axis suppression at recommended doses in children or adults 2, 4, 5
• No effect on growth in children at recommended doses (fluticasone propionate, mometasone furoate, and budesonide are safe; avoid beclomethasone dipropionate in children due to growth suppression risk) 2, 3
• No ocular effects (cataracts or glaucoma) with long-term use 2
• Safe for long-term continuous use—does not cause rhinitis medicamentosa (rebound congestion) unlike topical decongestants 2

Contraindications

• Hypersensitivity to fluticasone propionate or any component of the formulation 2

When to Escalate Therapy

• If severe nasal congestion prevents adequate drug delivery, consider adding a topical decongestant for 3–5 days maximum while initiating fluticasone 2
• For inadequate response to fluticasone alone after 2–4 weeks, consider adding intranasal azelastine (combination therapy provides >40% relative improvement over monotherapy) 2, 3
• For very severe or intractable symptoms, a short 5–7 day course of oral corticosteroids may be appropriate, but long-term or repeated parenteral corticosteroids are contraindicated 2, 3

Monitoring During Long-Term Use

• Periodically examine the nasal septum (every 6–12 months) to detect mucosal erosions that may precede septal perforation, a rare complication 2, 3
• After 6 months of daily use, reassess the need for continued therapy 1

Common Pitfalls to Avoid

• Do not prescribe "as needed" dosing—fluticasone requires regular daily use for optimal efficacy 2
• Do not combine with topical decongestants beyond 3–5 days—risk of rhinitis medicamentosa 2
• Do not use beclomethasone dipropionate as first-line in children—associated with growth suppression 2, 3
• Do not prescribe for children under 4 years—not FDA-approved 2, 1
• Ensure proper spray technique is taught—improper technique increases side effects and reduces efficacy 2, 3