What are the recommended dosing regimens of Flonase (fluticasone propionate nasal spray) for allergic rhinitis in adults, children (4‑11 years and ≥12 years), and for chronic rhinosinusitis with nasal polyps?

Flonase Dosing for Allergic Rhinitis and Nasal Polyps

Adults and Adolescents (≥12 years)

For allergic rhinitis, start with 2 sprays (100 µg) per nostril once daily in the morning (total 200 µg/day), which can be divided into twice-daily dosing if needed. 1, 2

• The standard starting dose is 2 sprays per nostril once daily, providing 200 µg total daily dose 1
• Once-daily morning dosing is as effective as twice-daily regimens and may improve compliance 3, 4, 5
• For patients with severe nasal congestion unresponsive to standard dosing, temporarily increase to 2 sprays per nostril twice daily (400 µg total) until symptoms are controlled, then reduce to maintenance dosing 2

For chronic rhinosinusitis with nasal polyps, use 2 sprays per nostril twice daily (400 µg/day total). 2

• The higher twice-daily regimen is specifically indicated for nasal polyps due to the more severe inflammatory burden 2
• After achieving control, attempt to reduce to the lowest effective maintenance dose 2

Children Ages 4–11 Years

Use 1 spray (50 µg) per nostril once daily in the morning (total 100 µg/day). 1, 2

• This lower dose is as effective as the 200 µg adult dose in pediatric patients 1, 6
• The 100 µg daily dose provides the advantage of once-daily dosing while maintaining demonstrated efficacy 1, 6
• Do not exceed 1 spray per nostril daily in this age group 1

Children Under 4 Years

Fluticasone propionate is not approved for children under 4 years of age. 1

• For children ages 2–3 years requiring intranasal corticosteroid therapy, consider mometasone furoate or triamcinolone acetonide, which are approved for this younger age group 1, 2

Administration Technique

Proper technique is critical to maximize efficacy and minimize side effects, particularly epistaxis. 1, 2

• Prime the bottle before first use by shaking and spraying until a fine mist appears 1
• Shake the bottle prior to each use 1
• Have the patient blow their nose before administration 1
• Keep the head upright during administration 1
• Use the contralateral hand technique: hold the spray in the opposite hand relative to the nostril being treated (e.g., right hand for left nostril) to naturally angle the spray away from the nasal septum 2
• This contralateral technique reduces epistaxis risk by four times compared to ipsilateral technique 2
• Instruct the patient to breathe in gently during spraying 1
• Do not close the opposite nostril during administration 2
• If using nasal saline irrigations, perform them before administering the steroid spray 2

Onset and Duration Expectations

Counsel patients that symptom relief begins within 12 hours but maximal efficacy requires days to weeks of continuous daily use. 1, 2

• Some patients experience benefit as early as 3–4 hours, but this is not universal 2
• Regular daily use is essential—this is maintenance therapy, not rescue therapy 1, 2
• For seasonal allergic rhinitis with predictable patterns, initiate treatment before symptom onset and continue throughout the allergen exposure period 2

Safety and Monitoring

Fluticasone propionate at recommended doses does not cause clinically significant systemic effects. 1, 2

• No hypothalamic-pituitary-adrenal (HPA) axis suppression occurs at standard doses in children or adults 1, 2, 6, 3, 4
• No effect on linear growth in children at recommended doses 1, 2
• No increased risk of cataracts, glaucoma, or elevated intraocular pressure with long-term use 2

The most common adverse effect is epistaxis (nosebleed), typically presenting as blood-tinged nasal secretions rather than frank bleeding. 1, 2

• Other common side effects include headache, pharyngitis, nasal burning or irritation, nausea, and cough 1, 2
• Local side effects are minimized with proper contralateral spray technique 1, 2
• For patients on long-term therapy (>6 months), examine the nasal septum every 6–12 months to detect early mucosal erosions that could precede septal perforation 2

Contraindications

Do not use in patients with documented hypersensitivity to fluticasone propionate or any component of the formulation. 1, 2

Common Pitfalls to Avoid

• Do not discontinue therapy when symptoms improve—this is maintenance therapy requiring continuous use for optimal control 2
• Do not use as-needed dosing—regular daily use is required to maintain efficacy 1
• Do not delay treatment waiting for allergy testing results—initiate therapy immediately upon clinical diagnosis 2
• Do not combine with oral antihistamines as initial therapy—intranasal corticosteroid monotherapy is equally effective and more cost-efficient 2
• Do not use topical decongestants for more than 3–5 days—they cause rebound congestion, whereas intranasal corticosteroids are safe for long-term daily use 2