Flovent and Arnuity Are NOT Equivalent for Vocal Cord Granuloma Treatment
Flovent (fluticasone propionate) is the preferred inhaled corticosteroid for vocal cord granulomas, while Arnuity (fluticasone furoate) has no established role in this condition. These medications are fundamentally different formulations designed for different anatomic targets, and the evidence specifically supports fluticasone propionate delivered via certain devices for laryngeal pathology.
Critical Distinction: Drug Formulation and Particle Size
Fluticasone propionate (Flovent) has been specifically studied for laryngeal conditions including eosinophilic esophagitis where swallowed topical steroids target upper aerodigestive tract inflammation 1, 2.
Particle size is crucial for laryngeal deposition. Computational fluid dynamics modeling demonstrates that larger particle sizes (8-10 μm) achieve optimal laryngeal deposition, with glottic deposition peaking at 10.8% for 9-μm particles when targeting vocal fold lesions 3.
Fluticasone propionate dry powder inhalers produce larger particles that are more suitable for laryngeal drug delivery compared to most metered-dose inhalers with 1-4 μm particles 3.
Arnuity Ellipta (fluticasone furoate) is a once-daily inhaled corticosteroid formulated specifically for lower airway delivery in asthma, with particle characteristics optimized for lung deposition, not laryngeal targeting 4.
Evidence for Fluticasone Propionate in Upper Airway Lesions
Swallowed fluticasone propionate (440-880 μg twice daily in adults) has demonstrated efficacy in treating inflammatory conditions of the upper aerodigestive tract, with patients instructed to spray the medication in the mouth without inhaling, then avoid eating/drinking for 30 minutes 1, 2.
The American Gastroenterological Association recommends topical fluticasone propionate as highly effective for inducing remission in eosinophilic esophagitis, a condition involving similar inflammatory pathways to vocal cord granulomas 2.
Fluticasone propionate has superior systemic potency compared to budesonide (3.7:1 ratio), which may contribute to its anti-inflammatory efficacy when used topically 5.
Why Arnuity Cannot Be Substituted
Arnuity is formulated as a once-daily medication with pharmacokinetics designed for sustained lower airway effects, not the topical laryngeal contact needed for granuloma treatment 4.
The delivery device matters significantly: Arnuity Ellipta uses a specific dry powder mechanism that cannot be adapted for the "swallow without inhaling" technique required for laryngeal targeting 2, 3.
No published evidence exists supporting Arnuity (fluticasone furoate) for vocal cord granulomas or any laryngeal pathology.
Practical Treatment Approach for Vocal Cord Granulomas
Use fluticasone propionate MDI or DPI (preferably DPI for larger particle size), with patients spraying into the mouth without inhaling, then swallowing 2, 3.
Dosing should be 440-880 μg twice daily based on extrapolation from eosinophilic esophagitis protocols 1, 2.
Instruct patients to avoid eating, drinking, or rinsing for 30 minutes after administration to maximize laryngeal contact time 2.
Address underlying causes concurrently: gastroesophageal reflux treatment, voice rest, and avoidance of phonotrauma are essential as inhaled steroids alone address only the inflammatory component 6.
Important Safety Considerations
Monitor for laryngeal candidiasis, which occurred in multiple patients treated with swallowed fluticasone propionate for upper airway conditions 1.
Laryngoscopy is recommended if hoarseness worsens during high-dose fluticasone treatment, as laryngeal aspergillosis has been reported with chronic use 7.
Systemic side effects are minimal at recommended doses for topical laryngeal application 2.
Bottom Line
Do not substitute Arnuity for Flovent in vocal cord granuloma treatment. The medications have different formulations, particle sizes, delivery mechanisms, and intended anatomic targets. Only fluticasone propionate (Flovent) has evidence supporting its use in laryngeal pathology when administered using the swallowed topical technique 1, 2, 3.