Veramyst

Action

Unknown. Has potent vasoconstrictive and anti-inflammatory properties.

Availability

fluticasone propionate

Inhalation aerosol, metered (Flovent HFA): 44 mcg, 110 mcg, 220 mcg

Inhalation powder, metered (Flovent Diskus): 50 mcg, 100 mcg, 250 mcg

Nasal spray (Flonase): 50 mcg

Topical cream (Cutivate): 0.005%

Topical ointment (Cutivate): 0.005%

fluticasone furoate

Nasal spray (Veramyst): 27.5 mcg fluticasone furoate in each 50-microliter spray in 10-g bottle containing 120 sprays

Indications and dosages

➣ Prophylaxis of asthma and treatment of asthma for patients requiring oral corticosteroid therapy (Flovent HFA and Flovent Diskus)

Adults and children age 4 and older: Recommended starting dosage and highest recommended dosage, based on prior asthma therapy, are listed in charts below.

Recommended Flovent FHA dosages

For Adults and adolescents age 12 and older

Recommended Flovent Diskus dosages

➣ Seasonal and perennial allergic and nonallergic rhinitis (Flonase)

Adults: Two sprays in each nostril daily or one spray in each nostril b.i.d. After first few days, may reduce dosage to one spray in each nostril daily; some patients may find p.r.n. use of two sprays in each nostril daily effective for symptom control. Maximum dosage is 200 mcg daily (two sprays in each nostril).

Adolescents and children ages 4 and older: Initially, one spray in each nostril daily. If patient doesn't respond, may increase to two sprays in each nostril. Once adequate control is achieved, reduce dosage to one spray in each nostril daily.

➣ Symptoms of seasonal and perennial allergic rhinitis (Veramyst)

Adults and adolescents age 12 and older: 110 mcg (2 sprays per nostril) once daily

Children ages 2 to 11: 55 mcg (1 spray per nostril) once daily

➣ Inflammatory and pruritic manifestations of corticosteroid-responsive atopic dermatoses

Adults and children ages 3 months and older: Apply thin film of Cutivate cream to affected skin area once or twice daily.

➣ Other corticosteroid-responsive dermatoses

Adults and children ages 3 months and older: Apply thin film of Cutivate cream to affected skin area b.i.d.

Contraindications

• Hypersensitivity to drug or its components

• Primary treatment of status asthmaticus or other acute asthma episodes necessitating intensive measures (Flovent FHA, Flovent Diskus)

• Severe allergy to milk proteins (Flovent Diskus)

Precautions

Use cautiously in:

• recurrent epistaxis, recent nasal septal ulcer, nasal surgery, or trauma

• severe hepatic disease (Veramyst)

• glaucoma and cataracts

• tuberculosis; respiratory tract infection; fungal, bacterial, viral, or parasitic infections; ocular herpes simplex

• hypercorticism and adrenal suppression (when used at higher than recommended dosages or in susceptible persons)

• concurrent use of other CYP3A inhibitors (such as ketoconazole; use not recommended with ritonavir)

• Candida albicans infection (Flovent, Veramyst)

• elderly patients (Flonase, Veramyst)

• pregnant or breastfeeding patients (Flovent, Flonase, Veramyst)

• children younger age than 4 (Flonase, Flovent)

• children younger than age 2 (Veramyst).

Administration

• Know that Flonase may cause immediate hypersensitivity reaction (contact dermatitis).

• Be aware that topical ointment should be used in adults only.

• Prime Veramyst nasal spray before first use, when not used for more than 30 days, or if cap has been left off bottle for 5 days or more.

• Administer inhalation powder by oral inhalation only.

Adverse reactions

CNS: Cutivate ointment-lightheadedness; Flonase-headache, dizziness; Flovent-headache, dizziness, giddiness; Veramyst-headache

EENT: Flonase-cataract, glaucoma, increased intraocular pressure, epistaxis, nasal burning or irritation, bloody nasal mucus, runny nose, pharyngitis; Flovent-cataract, glaucoma, nasal congestion, nasal septum perforation, nasal discharge, nasal sinus pain, sinusitis, rhinitis, allergic rhinitis, pharyngitis, dysphonia; Veramyst-cataract, glaucoma, increased intraocular pressure, epistaxis, pharyngolaryngeal pain, nasal ulceration

GI: Flonase-nausea, vomiting, diarrhea, abdominal pain; Flovent-nausea, vomiting, diarrhea, dyspepsia, stomach disorder, oral candidiasis

GU: Flovent-dysmenorrhea

Metabolic: Flovent, Veramyst-hypercorticism and adrenal suppression

Musculoskeletal: Flonase-aches and pains; Flovent-joint pain, limb pain, sprain, strain, aches and pains, reduced bone mineral density; Veramyst-back pain

Respiratory: Flonase-asthma symptoms, cough, bronchitis, wheezing (rare); Flovent-upper respiratory tract infection, influenza, bronchitis, chest congestion, bronchospasm; Veramyst-cough

Skin: Cutivate cream-pruritus, skin dryness, skin burning, erythematous rash, dusky erythema, eczema exacerbation, skin irritation, urticaria; Cutivate ointment-skin burning or irritation, hypertrichosis, increased erythema, hives; Flovent-urticaria, rash, skin eruption

Other: Cutivate cream or ointment-numbness of fingers, facial or nonfacial telangiectasia; Flonase-fever, flulike symptoms, hypersensitivity reaction; Flovent-dental problems, fever, C. albicans infection, immunosuppression, immediate or delayed hypersensitivity reactions, angioedema; anaphylaxis; Veramyst-pyrexia

Interactions

Drug-drug. Ketoconazole, other strong CYP3A inhibitors: increased fluticasone exposure (with Flonase, Flovent, Veramyst)

Ritonavir: increased systemic corticosteroid effects (with Flonase, Flovent, Veramyst)

Drug-diagnostic tests. Adrenocorticotropic hormone stimulation test, plasma cortisol test, urinary free cortisol test: interference with test results

Patient monitoring

☞ Monitor patient for withdrawal symptoms after Flovent is discontinued.

• Stay alert for systemic corticosteroid effects when administering Flovent, Flonase, or Veramyst.

• Observe for reduced growth rate in child or adolescent using Flovent, Flonase, or Veramyst.

• When giving Flovent, watch for eosinophilic conditions, such as Churg-Strauss syndrome.

☞ When giving Flonase, assess for epistaxis, wheezing, nasal septum perforation, cataracts, glaucoma, and increased intraocular pressure (rare reaction).

☞ When giving Veramyst, assess for epistaxis, nasal septum perforation, cataracts, glaucoma, and increased intraocular pressure (rare reaction).

Patient teaching

• Tell patient to take drug exactly as prescribed.

• Teach patient proper use of prescribed form.

☞ Advise patient to immediately report signs of allergic reaction.

• Caution patient to avoid exposure to people with chickenpox or measles.

• Advise female patient taking Flonase, Flovent, or Veramyst to inform prescriber if she is pregnant or breastfeeding.

• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.