What is the recommended dose, administration technique, side effects, and precautions for fluticasone propionate nasal spray in adults and children over two with allergic rhinitis?

Fluticasone Propionate Nasal Spray for Allergic Rhinitis

Fluticasone propionate nasal spray is the most effective first-line treatment for allergic rhinitis in adults and children ≥4 years, dosed as 1 spray (50 µg) per nostril once daily for children 4–11 years and up to 2 sprays per nostril once daily for those ≥12 years, with an excellent safety profile including no growth suppression or HPA-axis effects at recommended doses. 1, 2

Dosing Recommendations

Adults and Adolescents (≥12 years)

• Standard dose: 2 sprays (100 µg total) per nostril once daily in the morning (200 µg total daily dose) 1, 2, 3
• Severe congestion: May temporarily increase to 2 sprays per nostril twice daily (400 µg total) until symptoms controlled, then reduce to maintenance dose 1
• Maximum duration before physician consultation: 6 months of continuous daily use 3

Children (4–11 years)

• Standard dose: 1 spray (50 µg) per nostril once daily (100 µg total daily dose) 1, 2, 4
• Maximum duration before physician consultation: 2 months per year 3
• Important: The 100 µg daily dose is as effective as 200 µg in children and should not be exceeded 4

Children Under 4 Years

• Fluticasone propionate is not approved for children <4 years 1, 2
• Alternative options include mometasone furoate or triamcinolone acetonide, which are approved for children ≥2 years 1

Proper Administration Technique

Critical steps to maximize efficacy and minimize side effects:

• Prime the pump before first use by spraying away from face until fine mist appears 1, 2
• Shake the bottle vigorously before each use 1, 2
• Blow nose to clear nasal passages before administration 1, 2
• Keep head upright during administration (do not tilt head back) 1, 2
• Use contralateral hand technique: Hold spray in opposite hand relative to nostril being treated (right hand for left nostril, left hand for right nostril) to direct spray away from nasal septum—this reduces epistaxis risk by fourfold 1
• Breathe in gently during spraying 1, 2
• Do not close the opposite nostril during administration 1
• Never spray into eyes or mouth 3

If Using Nasal Saline Irrigation

• Perform saline irrigation before administering fluticasone spray to avoid washing out the medication 1

Onset of Action and Treatment Duration

• Initial symptom relief: Begins within 12 hours, with some patients experiencing benefit as early as 3–4 hours 1
• Maximum efficacy: Requires several days to weeks of continuous daily use 1, 2, 3
• Minimum trial period: 8–12 weeks to adequately assess therapeutic benefit 1
• Maintenance therapy: Continue daily use throughout allergen exposure period; do not use "as needed" 1, 2

Common pitfall: Patients often discontinue therapy when symptoms improve. Emphasize that fluticasone is maintenance therapy, not rescue therapy, and must be used continuously during allergen exposure to maintain relief. 1

Side Effects

Common Local Effects

• Epistaxis (nosebleeds): Most frequent adverse event, typically blood-tinged secretions rather than severe bleeding; occurs in 4–8% short-term, up to 20% with year-long use 1, 2, 4
• Nasal irritation or burning: Common, especially with propylene glycol-containing formulations 1, 2
• Headache: Frequently reported 1, 2
• Pharyngitis (throat irritation): Common 1, 2, 4
• Cough, nausea, or vomiting: May occur 2

Rare Serious Effects

• Nasal septal perforation: Rare; can be prevented with proper contralateral spray technique 1

Systemic Safety Profile

• No HPA-axis suppression at recommended doses in children or adults 1, 4, 5, 6
• No growth suppression in children at approved doses (100 µg daily for ages 4–11) 1, 4
• No ocular effects (cataracts, glaucoma, elevated intraocular pressure) with long-term use 1
• No bone density effects at standard doses 1
• Does not increase blood pressure when used as directed 3

Contraindications and Precautions

Absolute Contraindications

• Hypersensitivity to fluticasone propionate or any component of the formulation 1, 2

Require Physician Consultation Before Use

• HIV medications (ritonavir): May increase fluticasone levels 3
• Ketoconazole (oral antifungal): May increase fluticasone levels 3
• Concurrent systemic corticosteroids for asthma, allergies, skin conditions, or eye conditions 3

Monitoring Requirements

• Periodic nasal septum examination (every 6–12 months) during long-term use to detect mucosal erosions that may precede perforation 1
• Physician follow-up if children 4–11 years require use >2 months per year 3
• Physician follow-up if adults/adolescents ≥12 years require use >6 months continuously 3

When to Escalate Therapy

If inadequate response after 2–4 weeks of fluticasone monotherapy:

• Add intranasal antihistamine (azelastine) rather than oral antihistamine—combination provides >40% relative improvement over either agent alone 1
• Do not add oral antihistamines to intranasal corticosteroids as initial therapy; no additional benefit for nasal symptoms 1

If no improvement after 3 months:

• Consider short course (5–7 days) of oral corticosteroids or proceed to CT imaging and surgical evaluation 1

Important Clinical Caveats

• Do not share bottles between patients—spreads germs via nasal contact 3
• Bottle longevity: After labeled number of sprays used, each spray may not deliver full dose even if liquid remains 3
• Not for acute rescue: Unlike decongestants, fluticasone requires regular daily use for efficacy 1, 3
• Seasonal allergies: May initiate before symptom onset and continue throughout allergen exposure period for optimal control 1
• Perennial allergies: Requires year-round daily therapy due to continuous allergen exposure 1, 5