fluticasone (nasal)

Absorption: <2%; action is primarily local following nasal use.

Distribution: Crosses the placenta and enters breast milk in small amounts.

Metabolism/Excretion: Rapidly and extensively metabolized by the liver; primarily excreted in feces; <5% excreted in urine.

Half-Life: 7.8 hr.

Time/Action Profile ⬆ ⬇

(improvement in symptoms)

ROUTE	ONSET	PEAK	DURATION
Intranasal	few days	up to 3 wk	unknown

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Hypersensitivity (Flonase contains alcohol).

Use Cautiously in:

Active untreated infections;
Diabetes;
Glaucoma or cataracts;
Underlying immunosuppression (due to disease or concurrent therapy);
Systemic corticosteroid therapy (should not be abruptly discontinued when intranasal therapy is started);
Concurrent use of ritonavir;
Recent nasal trauma, septal ulcers, or surgery (wound healing may be impaired by nasal corticosteroids);
OB: Safety not established in pregnancy;
Lactation: Use while breastfeeding only if potential maternal benefit outweighs potential risk to infant;
Pedi: Children 17 yr (for Xhance), 4 yr (for Flonase Allergy Relief), or 2 yr (for Flonase Sensimist) (safety not established; prolonged or high-dose therapy may lead to complications).

Adv. Reactions/Side Effects ⬆ ⬇

Derm: rash, urticaria

EENT: cataracts, epistaxis, glaucoma, nasal burning, nasal irritation, nasopharyngeal fungal infection, pharyngitis

Endo: adrenal suppression (↑ dose, long-term therapy only), ↓growth (children)

GI: nausea, vomiting

Neuro: headache

Resp: cough

Misc: hypersensitivity reactions (including anaphylaxis and angioedema)

Interactions ⬆ ⬇

Drug-drug:

Strong CYP3A4 inhibitors, including atazanavir, clarithromycin, conivaptan, itraconazole, ketoconazole, lopinavir, nefazodone, nelfinavir, ritonavir, and voriconazole may ↑ levels; concurrent use not recommended.

Route/Dosage ⬆ ⬇

Seasonal or Perennial Allergic Rhinitis

(Adults and Children ≥12 yr): Flonase Sensimist Allergy Relief (OTC) and Flonase Allergy Relief (OTC): 2 sprays in each nostril once daily; after 1 wk, may adjust to 1–2 sprays in each nostril once daily; discuss with provider if need to continue longer than 6 mo.
(Children 4–11 yr): Flonase Allergy Relief (OTC): 1 spray in each nostril once daily; discuss with provider if need to continue longer than 2 mo.
(Children 2–11 yr): Flonase Sensimist Allergy Relief (OTC): 1 spray in each nostril once daily; discuss with provider if need to continue longer than 2 mo.

Nonallergic Rhinitis

(Adults ): Fluticasone Rx: 2 sprays in each nostril once daily or 1 spray in each nostril twice daily (not to exceed 2 sprays in each nostril/day); after several days, attempt to ↓ dose to 1 spray in each nostril once daily.
(Children ≥4 yr): Fluticasone Rx: 1 spray in each nostril once daily; may ↑ to 2 sprays in each nostril once daily if no response; once symptoms controlled, attempt to ↓ dose to 1 spray in each nostril once daily.

Chronic Rhinosinusitis with Nasal Polyps

(Adults ): Xhance: 1 spray in each nostril twice daily; may adjust to 2 sprays in each nostril twice daily.

Availability ⬆ ⬇

(Generic available)

Nasal spray: 50 mcg/metered spray in 16-g bottle (delivers 120 metered sprays)
Nasal spray (Avamys): 27.5 mcg/spray in 4.5-g bottle (delivers 30 metered sprays) and 10-g bottle (delivers 120 metered sprays)
Nasal spray (Flonase Allergy Relief): 50 mcg/metered spray in 9.9-mL bottle (delivers 60 metered sprays)OTC
Nasal spray (Flonase Sensimist Allergy Relief): 27.5 mcg/spray in 9.9-mL bottle (delivers 60 metered sprays) OTC
Nasal spray (Xhance): 93 mcg/spray in 16-mL bottle (delivers 120 metered sprays)
In combination with: azelastine (Dymista); see Appendix [not included in this PDA edition]).

Assessment ⬆ ⬇

Monitor degree of nasal stuffiness, amount and color of nasal discharge, and frequency of sneezing.
- Patients on long-term therapy should have periodic otolaryngologic examinations to monitor nasal mucosa and passages for infection or ulceration.
- Monitor growth rate in children receiving chronic therapy; use lowest possible dose.
Monitor for signs and symptoms of hypersensitivity reactions (rash, pruritus, swelling of face and neck, dyspnea) periodically during therapy.

Lab Test Considerations:

Periodic adrenal function tests may be ordered to assess degree of hypothalamic-pituitary-adrenal (HPA) axis suppression in chronic therapy. Children and patients using higher than recommended doses are at highest risk for HPA suppression.

Implementation ⬆ ⬇

Do not confuse Flonase with Flovent.
After the desired clinical effect has been obtained, attempts should be made to decrease dose to lowest amount. Gradually decrease dose every 2–4 wk as long as desired effect is maintained. If symptoms return, dose may briefly return to starting dose.
Intranasal: Patients also using a nasal decongestant should be given decongestant 5–15 min before corticosteroid nasal spray. If patient is unable to breathe freely through nasal passages, instruct patient to blow nose gently in advance of medication administration.

Patient/Family Teaching ⬆ ⬇

Advise patient to take medication exactly as directed. Take missed doses as soon as remembered unless almost time for next dose.
Instruct patient in correct technique for administering nasal spray (see Medication Administration Techniques). Shake well before use. Before first-time use, prime unit by spraying 6 times. If not used for at least 7 days or if cap left off for more than 5 days, reprime unit. Warn patient that temporary nasal stinging may occur.
Instruct patient to gently blow nose to clear nostrils prior to administering dose.
Instruct patient to stop fluticasone and notify health care professional immediately if signs of anaphylaxis (rash, hives, difficulty breathing, swollen lips or throat) occur.
Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking other Rx, OTC, or herbal products.
Rep: Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding.
Instruct patient to notify health care professional if symptoms do not improve within 1 mo or if symptoms worsen.

section name header

Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇