Introduction
Flonase (fluticasone propionate) is a corticosteroid nasal spray approved for the management of allergic and non-allergic rhinitis symptoms. As an intranasal glucocorticoid, it represents a first-line treatment option for persistent nasal symptoms, providing localized anti-inflammatory effects with minimal systemic absorption when used at recommended doses.
Mechanism of Action
Fluticasone propionate exerts its therapeutic effects through binding to glucocorticoid receptors in the nasal mucosa. This receptor complex translocates to the cell nucleus, where it modulates gene transcription resulting in:
- Inhibition of inflammatory cytokine production (IL-4, IL-5, IL-13)
- Reduction in mast cell activation and mediator release
- Decreased eosinophil migration and survival
- Stabilization of vascular permeability
- Inhibition of IgE production
The net effect is comprehensive suppression of the inflammatory cascade responsible for allergic rhinitis symptoms, typically achieving maximal effect within several days of regular use.
Indications
FDA-approved indications:
- Seasonal allergic rhinitis in adults and children ≥4 years
- Perennial allergic rhinitis in adults and children ≥4 years
- Non-allergic rhinitis in adults and children ≥12 years
Off-label uses (with clinical evidence):
- Nasal polyposis
- Eustachian tube dysfunction
- Adjunctive treatment in acute rhinosinusitis
Dosage and Administration
Standard dosing:- Adults and children ≥12 years: 2 sprays per nostril once daily or 1 spray per nostril twice daily
- Children 4-11 years: 1 spray per nostril once daily
1. Shake bottle gently before use 2. Prime pump with 6 actuations or until fine spray appears 3. Gently blow nose to clear nostrils 4. Tilt head slightly forward and insert nozzle into nostril 5. Aim spray away from nasal septum toward lateral wall 6. Breathe in gently through nose while spraying 7. Repeat in other nostril 8. Avoid sneezing or blowing nose immediately after administration
Special populations:- Hepatic impairment: No dosage adjustment required
- Renal impairment: No dosage adjustment required
- Geriatric patients: No dosage adjustment required
- Pregnancy: Category C - use only if potential benefit justifies potential risk
Pharmacokinetics
Absorption: Minimal systemic absorption (<2%) following intranasal administration. Bioavailability is primarily due to swallowed portion that undergoes first-pass metabolism. Distribution: Extensive tissue distribution with volume of distribution approximately 4.2 L/kg. High protein binding (91%). Crosses blood-brain barrier poorly. Metabolism: Extensive first-pass metabolism via cytochrome P450 3A4 in liver and gastrointestinal mucosa to inactive 17β-carboxylic acid derivative. Elimination: Primarily excreted in feces (<5% recovered in urine). Terminal elimination half-life approximately 8 hours.Contraindications
- Hypersensitivity to fluticasone propionate or any component of the formulation
- Recent nasal surgery or nasal trauma until healing has occurred
- Active or quiescent untreated tuberculosis infections
- Untreated fungal, bacterial, or viral systemic infections
- Ocular herpes simplex
Warnings and Precautions
Systemic effects: Although minimal systemic absorption occurs, potential for hypothalamic-pituitary-adrenal (HPA) axis suppression with higher than recommended doses or concomitant systemic corticosteroids. Nasal effects: Nasal septal perforations, epistaxis, and nasal ulceration have been reported. Monitor patients periodically for nasal mucosal changes. Immunosuppression: Potential increased risk of infections. Avoid use in patients with active or quiescent tuberculosis infections or untreated fungal, bacterial, or viral infections. Ophthalmic effects: Glaucoma and cataracts have been reported with intranasal corticosteroids. Monitor patients with pre-existing glaucoma regularly. Growth suppression: Monitor growth in pediatric patients receiving prolonged therapy.Drug Interactions
Strong CYP3A4 inhibitors: Ketoconazole, ritonavir, clarithromycin - may increase fluticasone systemic exposure. Use caution with concomitant administration. Other corticosteroids: Additive systemic effects may occur with concomitant systemic corticosteroid therapy. Live vaccines: Avoid administration of live vaccines during therapy due to potential immunosuppression.Adverse Effects
Common (>10%):- Epistaxis (nosebleeds)
- Nasal irritation
- Headache
- Pharyngitis
- Nasal congestion
- Cough
- Nasal dryness
- Sneezing
- Sinusitis
- Nausea
- Nasal septal perforation
- Glaucoma
- Cataracts
- Anaphylaxis
- Impaired wound healing
Monitoring Parameters
Therapeutic monitoring:- Symptom improvement (sneezing, rhinorrhea, nasal congestion)
- Quality of life measures
- Nasal examination for mucosal integrity
- Nasal mucosa examination at regular intervals
- Growth monitoring in pediatric patients
- Intraocular pressure in patients with glaucoma risk factors
- Signs of HPA axis suppression with long-term high-dose use
Patient Education
Proper administration:- Demonstrate correct technique using manufacturer instructions
- Emphasize aiming away from nasal septum
- Explain need for regular use (not PRN) for optimal effect
- Advise that full benefit may take several days to develop
- Maximum benefit typically achieved within 3-4 days of regular use
- Use consistently even when symptoms improve
- Contact healthcare provider if no improvement after 3 weeks
- Report any nasal pain, bleeding, or crusting
- Inform all healthcare providers of Flonase use
- Not for emergency relief of acute symptoms
- Keep out of eyes; rinse with water if contact occurs
- Store at room temperature (20-25°C/68-77°F)
- Discard after 120 actuations after priming
- Do not freeze
References
1. FDA Prescribing Information: Flonase Nasal Spray 2. Sur DKC, Plesa ML. Treatment of Allergic Rhinitis. Am Fam Physician. 2015;92(11):985-992. 3. Dykewicz MS, Wallace DV, Baroody F, et al. Treatment of seasonal allergic rhinitis: An evidence-based focused 2017 guideline update. Ann Allergy Asthma Immunol. 2017;119(6):489-511. 4. Benninger MS, Ahmad N, Marple BF. The safety of intranasal steroids. Otolaryngol Head Neck Surg. 2003;129(6):739-750. 5. Derendorf H, Meltzer EO. Molecular and clinical pharmacology of intranasal corticosteroids: clinical and therapeutic implications. Allergy. 2008;63(10):1292-1300. 6. Ratner PH, van Bavel JH, Martin BG, et al. A comparison of the efficacy of fluticasone propionate aqueous nasal spray and loratadine, alone and in combination, for the treatment of seasonal allergic rhinitis. J Fam Pract. 1998;47(2):118-125.