Is intranasal fluticasone (Flonase) safe for a patient with well‑controlled glaucoma, and what monitoring or alternative therapies are recommended?

Flonase Use with Glaucoma

Intranasal fluticasone (Flonase) is safe for patients with well-controlled glaucoma and does not require routine discontinuation or dose adjustment. 1

Evidence Supporting Safety in Glaucoma Patients

The most direct evidence comes from high-quality guidelines and prospective research:

• Patients with glaucoma can safely use Flonase at recommended doses, as intranasal corticosteroids do not increase the risk of glaucoma or elevated intraocular pressure (IOP). 1

• Standard doses of intranasal corticosteroids are not associated with increased risk for development of glaucoma or elevated IOP, even with long-term use. 1

• Long-term intranasal steroid use has not been shown to increase IOP or cause other ocular symptoms in prospective trials. 1

• A randomized, double-masked, placebo-controlled trial in 22 adults with well-controlled open-angle glaucoma or ocular hypertension found no clinically significant increase in mean IOP after 6 weeks of twice-daily inhaled fluticasone propionate compared with placebo, and no participants exceeded their individualized target IOP. 2

• A prospective study of newer-generation intranasal steroids (mometasone furoate and fluticasone furoate) used for 6 months in 100 allergic rhinitis patients found no statistically significant IOP elevation during the treatment period. 3

Monitoring Recommendations

For patients on long-term intranasal steroids, consultation with their physician is recommended to determine if regular ophthalmic monitoring is appropriate. 1

• No routine monitoring is required for short-term use (less than 12 weeks). 1

• For patients already under ophthalmologic care for glaucoma, continue existing IOP monitoring schedules as determined by their ophthalmologist. 4

• Periodic examination of the nasal septum is recommended during long-term use to detect mucosal erosions that may precede septal perforation (a rare complication unrelated to glaucoma). 5

Important Caveats and Nuances

While the preponderance of evidence supports safety, one retrospective study found that discontinuing nasal steroids in 12 patients with glaucoma resulted in significant IOP reduction (mean decrease from 18.0 to 14.5 mm Hg), with 11 of 12 patients experiencing decreased IOP after discontinuation. 6 However, this study has important limitations:

• It was retrospective (lower quality evidence) versus the prospective randomized trial showing no effect. 6, 2
• The patients may have been steroid responders, a rare subgroup representing a small minority of the population. 6
• The FDA label notes that rare instances of glaucoma and increased IOP have been reported following intranasal corticosteroid use, but emphasizes these are uncommon. 7

Clinical Algorithm for Glaucoma Patients Requiring Intranasal Steroids

1. Initiate intranasal fluticasone at standard doses (2 sprays per nostril once daily for adults ≥12 years) without delay, as it is the most effective first-line treatment for allergic rhinitis. 5, 1

2. Ensure proper administration technique: direct spray away from nasal septum using contralateral hand technique to minimize local side effects. 5

3. For patients with well-controlled glaucoma already under ophthalmologic care: continue existing IOP monitoring schedule (typically every 3-6 months) without additional visits solely due to intranasal steroid use. 4, 1

4. For patients not currently monitored by ophthalmology: consider baseline IOP measurement if using intranasal steroids for >12 weeks, though routine monitoring is not required. 1

5. If IOP increases during intranasal steroid therapy: first verify adherence to glaucoma medications and rule out other causes of IOP elevation before attributing to intranasal steroids. 6

6. If IOP elevation is temporally related to intranasal steroid initiation: consider a trial of discontinuation for 4-6 weeks to assess whether IOP returns to baseline, though this scenario is rare. 6

Alternative Therapies (If Needed)

If a patient or provider remains concerned despite reassuring evidence, alternative options include:

• Intranasal antihistamines (azelastine) are less effective than intranasal corticosteroids but have no IOP concerns. 5

• Oral second-generation antihistamines are significantly less effective for nasal congestion but may be considered for milder symptoms. 5

• Intranasal cromolyn sodium has an excellent safety profile but is less effective than intranasal corticosteroids. 5

• Leukotriene receptor antagonists should not be used as primary therapy, as they are markedly less effective than intranasal corticosteroids. 5

Key Pitfall to Avoid

Do not withhold or discontinue intranasal corticosteroids in glaucoma patients based on theoretical concerns, as the evidence demonstrates safety and the alternative therapies are substantially less effective for controlling rhinitis symptoms that significantly impact quality of life. 5, 1