What are the recommended medications for treating congestion?

Recommended Medications for Treating Nasal Congestion

For nasal congestion, intranasal corticosteroids are the most effective first-line monotherapy, with short-term intranasal decongestants (≤3 days) for immediate relief in severe cases, and saline nasal irrigation as a safe adjunctive therapy for long-term use. 1

First-Line Treatments

Intranasal Corticosteroids

• Most effective monotherapy for nasal congestion
• Provide superior relief with minimal systemic side effects
• Recommended as first-line therapy for moderate-to-severe congestion 1
• Monitor growth in children using long-term therapy
• Limit use to 2 months per year in children 4-11 years and 6 months in adults before physician review

Saline Nasal Irrigation

• Safe adjunctive therapy for long-term use
• Helps thin secretions and remove allergens/irritants
• Buffered hypertonic (3%-5%) saline may have superior anti-inflammatory effects
• Improves quality of life and decreases medication use 1

Short-Term Relief Options

Intranasal Decongestants

• Oxymetazoline and xylometazoline provide faster and more targeted relief than oral decongestants
• Strictly limit use to ≤3 days to prevent rhinitis medicamentosa (rebound congestion) 1, 2
• Topical decongestants cause potent nasal vasoconstriction through alpha-adrenergic stimulation
• Development of rhinitis medicamentosa is highly variable and may occur within 3 days of use 1

Oral Decongestants

• Pseudoephedrine (60mg every 4-6 hours) is recommended over phenylephrine 1, 3
• Alpha-adrenergic agonists that reduce nasal congestion by acting systemically 4, 1
• Can cause side effects such as elevated blood pressure, palpitations, irritability, and sleep disturbance 4, 1
• FDA-approved for nasal congestion, sinus pressure, and sinus congestion 5
• Pseudoephedrine has been shown to be effective in reducing nasal airway resistance in clinical trials 6

Special Considerations

Contraindications and Cautions

• Oral decongestants should be used with caution in older adults and young children 4
• Avoid in patients with hypertension, cardiovascular disease, hyperthyroidism, glaucoma, and bladder neck obstruction 4, 1
• Not recommended for children under 6 years due to risk of serious adverse effects 1
• Monitor blood pressure in patients with controlled hypertension 1

Additional Options for Specific Symptoms

• Intranasal anticholinergics (ipratropium bromide) may effectively reduce rhinorrhea but have no effect on other nasal symptoms 4
• Concomitant use of ipratropium bromide nasal spray and an intranasal corticosteroid is more effective than either drug alone for treating rhinorrhea 4
• Second-generation antihistamines (fexofenadine, loratadine, desloratadine) are preferred over first-generation antihistamines for allergic rhinitis due to less sedation 4
• Intranasal antihistamines may be considered as first-line treatment for allergic and nonallergic rhinitis 4

Treatment Algorithm

1. For mild, intermittent congestion:

   • Start with saline nasal irrigation
   • Consider short-term intranasal decongestant (≤3 days) if needed for immediate relief

2. For moderate-to-severe congestion:

   • Intranasal corticosteroid as first-line therapy
   • Consider adding short-term intranasal decongestant (≤3 days) at initiation if severe congestion
   • Add saline nasal irrigation as adjunctive therapy

3. For congestion with rhinorrhea:

   • Consider adding intranasal anticholinergic (ipratropium bromide)

4. For congestion with allergic symptoms:

   • Add second-generation antihistamine or intranasal antihistamine
   • Consider oral anti-leukotriene agents alone or in combination with antihistamines 4

Safety Considerations

• Oral decongestants can cause systemic effects and should be avoided in patients with certain conditions 1
• Intranasal decongestants should never be used for more than 3 days due to risk of rhinitis medicamentosa 1, 2
• Severe cardiovascular and neurological adverse events can occur with ephedrine and pseudoephedrine even at low doses 7
• Cochrane review found that nasal decongestants do not seem to increase the risk of adverse events in adults in the short term 8