Should a patient with a history of seizures, currently on anti-epileptic (seizure) medications and with a history of aspiration pneumonia, be treated for a 24-hour nasal congestion?

From the Guidelines

For a patient with a known seizure history on maintenance medications and a history of aspiration pneumonia who has had nasal congestion for only 24 hours, I would recommend watchful waiting rather than immediate medication. Nasal congestion of short duration (24 hours) is likely due to a mild viral infection and often resolves spontaneously 1. If treatment becomes necessary, saline nasal sprays or rinses would be the safest first option, as they have no drug interactions with seizure medications and pose minimal risk of sedation that could increase aspiration risk. Some key points to consider in managing this patient's nasal congestion include:

• Avoiding medications containing pseudoephedrine or phenylephrine, as these decongestants may lower seizure threshold and interact with some antiepileptic drugs 1.
• Avoiding sedating antihistamines like diphenhydramine, which could increase the risk of aspiration in a patient with that history 1.
• Considering non-sedating antihistamines like loratadine (10mg daily) or cetirizine (10mg daily) if congestion persists beyond 3-4 days or worsens significantly, after checking for specific interactions with the patient's seizure medications 1. The key concern here is balancing symptom relief against the risks of triggering seizures or increasing aspiration risk through medication side effects, prioritizing the patient's morbidity, mortality, and quality of life 1.

From the FDA Drug Label

Temporarily relieves nasal congestion due to: common cold hay fever upper respiratory allergies sinusitis shrinks swollen nasal membrances so you can breathe more freely. The patient has a congested nose for 24 hours, which is a condition that oxymetazoline (IN) can help with.

• The patient's seizure history and aspiration pneumonia are important considerations, but there is no information in the provided drug labels that directly addresses the safety of using oxymetazoline (IN) in patients with these conditions. Given the lack of direct information, no conclusion can be drawn about the safety of using oxymetazoline (IN) in this patient, and it is recommended to consult a doctor before administering any medication 2.

From the Research

Nasal Congestion Treatment

• The patient's congested nose for 24 hours can be treated with conservative treatments, including decongestant pharmacotherapy, antiallergy measures, and nasal dilation devices 3.
• However, it is essential to consider the patient's history of aspiration pneumonia and seizure disorder when selecting a treatment.

Aspiration Pneumonia Risk

• The risk of aspiration pneumonia is not common in otherwise healthy adults with seizures, but the patient's history of aspiration pneumonia suggests a higher risk 4.
• The patient's seizure history and aspiration pneumonia may be related to impaired swallowing mechanisms or difficulty in attaining adequate patient positioning 4.

Treatment Considerations

• When treating the patient's nasal congestion, it is crucial to consider the potential risk of aspiration and select treatments that minimize this risk.
• Intranasal delivery of medications may be a viable option for treating seizures, but its use for nasal congestion treatment is not well-established 5.
• The patient's history and physical examination are essential in evaluating the first seizure and determining the specific acute or remote causes 6.

Seizure-Related Complications

• Foreign body aspiration is a potentially life-threatening complication of seizures, and the patient's history of aspiration pneumonia suggests a higher risk 7.
• It is essential to monitor the patient for signs of aspiration, such as chest pain or unexplained hemoptysis, and to take precautions to prevent foreign body aspiration during seizures 7.