What is the appropriate starting dose of fluticasone propionate nasal spray (Flonase) for a 12‑year‑old child?

Fluticasone Propionate (Flonase) Dosing for a 12-Year-Old

For a 12-year-old with allergic rhinitis, start with 2 sprays in each nostril once daily (total 200 mcg/day), which is the standard adult dose for patients ≥12 years of age. 1, 2, 3, 4

Age-Specific Dosing Guidelines

At age 12, your patient crosses into the adolescent/adult dosing category for fluticasone propionate nasal spray:

• Ages ≥12 years: 2 sprays per nostril once daily (200 mcg total daily dose) 1, 2, 3
• Ages 4–11 years: 1 spray per nostril once daily (100 mcg total daily dose) 1, 2, 3

Each spray delivers 50 mcg of fluticasone propionate, so two sprays per nostril equals 200 mcg total. 2, 3

Dosing Flexibility for Severe Symptoms

If nasal congestion is severe and does not respond to the standard once-daily dose, you may temporarily increase to 2 sprays per nostril twice daily (400 mcg total) until symptoms are controlled, then reduce back to the maintenance dose of 2 sprays per nostril once daily. 1 This higher dosing strategy is particularly useful for patients with severe congestion that has not responded to standard dosing. 1

Duration of Treatment Before Reassessment

• For patients ≥12 years: If daily use extends beyond 6 months, check with the patient to ensure continued need and assess for any adverse effects 4
• For children 4–11 years: If use exceeds 2 months per year, reassessment is recommended due to theoretical concerns about growth velocity 4

Since your patient is 12 years old, the 6-month threshold applies rather than the 2-month pediatric limit. 4

Critical Administration Technique

Proper technique is essential for efficacy and safety:

• Prime the bottle before first use by shaking and spraying away from the face until a fine mist appears 1, 2
• Shake the bottle before each use 1, 2
• Have the patient blow their nose before administration 1, 2
• Keep the head upright during spraying 1, 2
• Use the contralateral hand (right hand for left nostril, left hand for right nostril) to direct the spray away from the nasal septum—this reduces epistaxis risk by four times 1
• Have the patient breathe in gently during spraying 1, 2
• Do not close the opposite nostril during administration 1

Onset and Maintenance Expectations

Counsel the patient that symptom relief typically begins within 12 hours, but maximal benefit requires several days to weeks of continuous daily use. 1, 2 This is a common pitfall—patients may discontinue therapy prematurely if they expect immediate relief like with oral antihistamines. 1, 2

Emphasize daily use rather than as-needed dosing to maintain optimal symptom control, even when symptoms improve. 1, 2 Fluticasone propionate is a maintenance medication, not a rescue therapy. 1

Safety Profile at This Age

The safety profile for adolescents ≥12 years mirrors that of adults:

• No hypothalamic-pituitary-adrenal axis suppression at recommended doses 1, 5, 6, 7
• No effect on growth (though this is less relevant at age 12 when most linear growth is complete) 1
• No increased risk of cataracts or glaucoma with long-term use 1
• Most common side effect is epistaxis (blood-tinged nasal secretions), occurring in 4–8% of patients in short-term studies 1, 2
• Other common side effects include headache, pharyngitis, and nasal burning/irritation 1, 2, 3

Contraindications

Do not use fluticasone propionate if the patient has a documented hypersensitivity to fluticasone or any component of the formulation. 1, 2, 3

Check for drug interactions: Patients taking ritonavir (HIV medication) or ketoconazole should consult their physician before starting fluticasone propionate, as these medications can increase fluticasone levels. 4

When to Escalate Therapy

If the patient does not achieve adequate symptom control with intranasal fluticasone propionate alone after 2–3 weeks of regular use, add intranasal azelastine (an intranasal antihistamine) rather than an oral antihistamine. 1 The combination of fluticasone propionate plus azelastine provides more than 40% relative improvement compared to either agent alone. 1

Do not add an oral antihistamine to intranasal corticosteroid therapy as routine practice—multiple high-quality trials show no additional benefit for nasal symptoms. 1