Flunisolide (flunisolide)

After initial priming (5-6 sprays), the nasal inhaler delivers about 25 mcg of flunisolide per metered spray. The commercially available preparations deliver about 200 metered sprays. Dosage must be carefully adjusted according to individual requirements and response.

The therapeutic effects of intranasal corticosteroids, unlike those of decongestants, are not immediate. This should be explained to the patient in advance to ensure compliance and continuation of the prescribed treatment regimen. Full therapeutic benefit usually requires regular use and usually is evident within a few days. A longer period may be required in some patients. Response to the initial dosage generally should be assessed 4-7 days after starting therapy; about two-thirds of patients will experience some relief within this time period. Intranasal flunisolide should be discontinued in patients who do not experience clinically important benefit within 3 weeks of initiating therapy.

Flunisolide is administered by nasal inhalation using a special nasal inhaler. Patients should be carefully instructed in the use of the nasal inhaler. To obtain optimum results, patients should also be given a copy of the patient instructions provided by the manufacturer. An adult should carefully supervise a child in the administration of flunisolide nasal solution. The manufacturer states that flunisolide nasal solution should not be administered by oral inhalation, since the safety of polyethylene glycol in the vehicle of the nasal solution has not been established for this route of administration.

Prior to administration of flunisolide nasal solution, patients should clear their nasal passages; administration of a topical nasal decongestant about 5-15 minutes before flunisolide administration may be required in patients with blocked nasal passages during the first 2-3 days of therapy to ensure adequate penetration of the drug and to prevent loss of the drug from the nasal passages via excess secretions. Prior to initial use, the nasal inhaler must be assembled and primed. After assembly is complete, the patient should tilt his head slightly forward, insert the spray tip into one nostril, and point the tip toward the inflamed nasal turbinates and away from the nasal septum. For maximum therapeutic effect and to ensure adequate penetration of the drug, the patient should pump the drug into one nostril while holding the other nostril closed and should concurrently inspire through the nose; this procedure is then repeated for the other nostril.

The manufacturer recommends cleansing the nasal adapter and/or pump in warm water if the holes in the device become clogged. If the nasal inhaler is disassembled for any reason (including the cleansing procedure) or not used for 5 days or longer, it must be primed again prior to use. Opened containers of flunisolide nasal solution should be discarded after 3 months.

Although there have been no reports to date of clinically important drug interactions with flunisolide, it should be noted that phenobarbital and other agents that induce hepatic microsomal enzymes may enhance the metabolism of corticosteroids.

There are no contraindication interactions for this drug.

Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

Agents That Affect Iodide/Radioactive Iodide

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Many compounds can affect iodide protein binding and alter iodide pharmacokinetics and pharmacodynamics.(1)

CLINICAL EFFECTS: Compounds that affect iodide pharmacokinetics and pharmacodynamics may impact the effectiveness of radioactive iodide.(1)

PREDISPOSING FACTORS: Compounds that affect iodide pharmacokinetics and pharmacodynamics are expected to have the most impact during therapy using radioactive iodide. Diagnostic procedures would be expected to be impacted less.

PATIENT MANAGEMENT: Discuss the use of agents that affect iodide pharmacokinetics and pharmacodynamics with the patient's oncologist.(1) Because indocyanine green contains sodium iodide, the iodine-binding capacity of thyroid tissue may be reduced for at least one week following administration. Do not perform radioactive iodine uptake studies for at least one week following administration of indocyanine green.(2) The manufacturer of iopamidol states administration may interfere with thyroid uptake of radioactive iodine and decrease therapeutic and diagnostic efficacy. Avoid thyroid therapy or testing for up to 6 weeks post administration of iopamidol.(3)

DISCUSSION: Many agents interact with radioactive iodine. The average duration of effect is: anticoagulants - 1 week antihistamines - 1 week anti-thyroid drugs, e.g: carbimazole, methimazole, propylthiouracil - 3-5 days corticosteroids - 1 week iodide-containing medications, e.g: amiodarone - 1-6 months expectorants - 2 weeks Lugol solution - 3 weeks saturated solution of potassium iodine - 3 weeks vitamins - 10-14 days iodide-containing X-ray contrast agents - up to 1 year lithium - 4 weeks phenylbutazone - 1-2 weeks sulfonamides - 1 week thyroid hormones (natural or synthetic), e.g.: thyroxine - 4 weeks tri-iodothyronine - 2 weeks tolbutamide - 1 week topical iodide - 1-9 months (1)

Agents That Affect Iodide/Sodium Iodide I 131

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Many compounds can affect iodide protein binding and alter iodide pharmacokinetics and pharmacodynamics.(1,2)

CLINICAL EFFECTS: Compounds that affect iodide pharmacokinetics and pharmacodynamics may impact the effectiveness of radioactive iodide.(1,2)

PREDISPOSING FACTORS: Compounds that affect iodide pharmacokinetics and pharmacodynamics are expected to have the most impact during therapy using radioactive iodide. Diagnostic procedures would be expected to be impacted less.

PATIENT MANAGEMENT: Discuss the use of agents that affect iodide pharmacokinetics and pharmacodynamics with the patient's oncologist.(1,2) Because indocyanine green contains sodium iodide, the iodine-binding capacity of thyroid tissue may be reduced for at least one week following administration. Do not perform radioactive iodine uptake studies for at least one week following administration of indocyanine green.(3) The manufacturer of iopamidol states administration may interfere with thyroid uptake of radioactive iodine and decrease therapeutic and diagnostic efficacy. Avoid thyroid therapy or testing for up to 6 weeks post administration of iopamidol.(4)

DISCUSSION: Many agents interact with radioactive iodine. The average duration of effect is: anticoagulants - 1 week antihistamines - 1 week anti-thyroid drugs, e.g: carbimazole, methimazole, propylthiouracil - 3-5 days corticosteroids - 1 week iodide-containing medications, e.g: amiodarone - 1-6 months expectorants - 2 weeks Lugol solution - 3 weeks saturated solution of potassium iodine - 3 weeks vitamins - 10-14 days iodide-containing X-ray contrast agents - up to 1 year lithium - 4 weeks phenylbutazone - 1-2 weeks sulfonamides - 1 week thyroid hormones (natural or synthetic), e.g.: thyroxine - 4 weeks tri-iodothyronine - 2 weeks tolbutamide - 1 week topical iodide - 1-9 months (1,2)

There are no moderate interactions for this drug.

There is no enhanced messaging for this drug.

There are no contraindication contraindications for this drug.

• Nasal septal perforation
• Nasal septal ulcers
• Nasal trauma
• Ocular herpes simplex
• Ocular hypertension
• Open angle glaucoma
• Operation on nose
• Severe infection

• Adrenocortical insufficiency
• Cataracts
• Epistaxis
• Inactive tuberculosis
• Parasitic infection

There is no enhanced messaging for this drug.

Less Frequent

• Abdominal pain with cramps
• Cough
• Crusted nasal mucosa
• Dizziness
• Dysgeusia
• Epistaxis
• Headache disorder
• Hoarseness
• Lesion of nasal mucosa
• Lethargy
• Nausea
• Parosmia
• Rhinorrhea
• Sore throat
• Vomiting

Rare or Very Rare

• Growth failure
• Nasal candidiasis
• Nasal septal perforation
• Ocular hypertension
• Pharyngeal candidiasis

More Frequent

• Dry nose
• Nasal passage irritation

Less Frequent

• Sneezing

No enhanced messaging available.

No enhanced messaging available.

Flunisolide nasal solution should be used during pregnancy only when the potential benefits justify the possible risks to the fetus. Since adrenal insufficiency may occur in neonates born to women who received corticosteroids during pregnancy, these neonates should be carefully monitored for signs and symptoms of this condition. Although there are no adequate and controlled studies to date in humans, flunisolide has been shown to be teratogenic and fetotoxic in rabbits and rats at oral dosages of 40 and 200 mcg/kg per day, respectively. Teratogenic effects in these animals included cleft palate and reduced ossification, which are similar to observations noted with other corticosteroids.

Flunisolide should be used with caution in nursing women, since it is not known whether the drug is distributed into milk. Other corticosteroids are distributed into milk and may cause adverse effects such as growth suppression in nursing infants.

No enhanced messaging available.