What complications are associated with prolonged use of over-the-counter (OTC) nasal spray, presenting with erythematous and swollen mucosa without purulent discharge after 2 weeks of use?

From the Guidelines

Prolonged use of over-the-counter nasal sprays can lead to severe complications, including rebound congestion, nasal dryness, and rhinitis medicamentosa, as evident in the erythematous and swollen mucosa, and therefore, immediate discontinuation and alternative treatments should be considered. The patient's symptoms of erythematous and swollen mucosa without purulent discharge after 2 weeks of use are likely indicative of rhinitis medicamentosa, a condition caused by the prolonged use of topical decongestants 1. Some key complications associated with prolonged use of OTC nasal sprays include:

• Rebound congestion, which can lead to a cycle of dependency and worsening of symptoms
• Nasal dryness and irritation, which can cause discomfort and increase the risk of infection
• Epistaxis (nosebleeds), which can be a serious complication, especially in patients with underlying bleeding disorders
• Damage to nasal cilia, which can impair the natural cleaning mechanism of the nasal passages and increase the risk of infection
• Systemic effects, such as increased blood pressure and heart palpitations, which can be a concern in patients with underlying cardiovascular disease Treatment of rhinitis medicamentosa requires discontinuation of the decongestant spray, which can be managed by tapering use gradually, alternating nostrils, or switching to saline sprays or intranasal corticosteroids under medical supervision, as suggested by the clinical practice guideline update on adult sinusitis 1. It is essential to address the underlying cause of the nasal congestion and to use alternative treatments that are safer and more effective in the long term, rather than relying on prolonged use of OTC nasal sprays. The mechanism of rhinitis medicamentosa involves alpha-adrenergic receptor downregulation and vascular damage from repeated vasoconstriction and subsequent vasodilation cycles, which can be prevented by limiting the use of topical decongestants to 3-5 consecutive days without a prolonged intervening drug-free period 1.

From the FDA Drug Label

Patients using Fluticasone Propionate Nasal Spray, USP, over several months or longer should be examined periodically for evidence of Candida infection or other signs of adverse effects on the nasal mucosa Rare instances of wheezing, nasal septum perforation, cataracts, glaucoma, and increased intraocular pressure have been reported following the intranasal application of corticosteroids, including fluticasone propionate. In addition to adverse events reported from clinical trials, the following events have been identified during postapproval use of intranasal fluticasone propionate in clinical practice... Ear, Nose, and Throat Alteration or loss of sense of taste and/or smell and, rarely, nasal septal perforation, nasal ulcer, sore throat, throat irritation and dryness, cough, hoarseness, and voice changes.

The complications associated with prolonged use of over-the-counter (OTC) nasal spray, presenting with erythematous and swollen mucosa without purulent discharge after 2 weeks of use, may include:

• Candida infection
• Nasal septum perforation
• Nasal ulcer
• Local irritation These complications are based on the information provided in the drug labels for fluticasone propionate nasal spray 2 and 3.

From the Research

Complications of Prolonged OTC Nasal Spray Use

• Rebound mucosal swelling and rhinitis medicamentosa are potential complications of prolonged use of over-the-counter (OTC) nasal sprays, as reported in studies 4, 5.
• Rhinitis medicamentosa is characterized by nasal hyperreactivity, mucosal swelling, and tolerance, and can be induced or aggravated by the overuse of topical vasoconstrictors with or without a preservative 5.
• The use of preservatives such as benzalkonium chloride in nasal decongestant sprays can accentuate the severity of rhinitis medicamentosa and induce mucosal swelling 5.
• Prolonged use of OTC nasal sprays can lead to rebound congestion, nasal hyperreactivity, and histologic changes of the nasal mucosa 5, 6.

Symptoms and Treatment

• Symptoms of rhinitis medicamentosa include nasal stuffiness, congestion, and hyperreactivity, and can be estimated on visual analog scales 4.
• Treatment of rhinitis medicamentosa typically involves withdrawal of the vasoconstrictor and use of a topical corticosteroid to alleviate the withdrawal process 5.
• Topical corticosteroid nasal sprays can be effective in reducing inflammation and relieving symptoms of allergic rhinitis, but may take up to two weeks to become effective 7, 8.
• Patients should be advised to use corticosteroid nasal sprays daily and to prepare the nose through cleansing, such as nasal douching, to enhance the effectiveness of the treatment 7.