What are the recommended treatments for nasal congestion?

Recommended Treatments for Nasal Congestion

Intranasal corticosteroids are the most effective first-line medication for nasal congestion, while oral and topical decongestants should be used only for short-term relief with specific precautions. 1

First-Line Treatments

Intranasal Corticosteroids

• Most effective medication class for controlling all major symptoms of nasal congestion 1
• Can be used safely for up to 6 months
• Recommended dosage example: Flonase 200mcg once daily (2 sprays in each nostril) or 100mcg twice daily 1
• Associated with reduction in Eustachian tube dysfunction when nasal congestion is effectively treated

Saline Irrigation

• Buffered hypertonic (3%-5%) saline is completely safe with no cardiovascular effects 1
• Provides modest benefit for symptom relief
• Helps clear mucus and moisturize nasal passages

Second-Line Treatments

Antihistamines

• Second-generation antihistamines (fexofenadine, loratadine, desloratadine) can be used as adjuncts to intranasal corticosteroids 1
• Minimal sedation at recommended doses
• Combination therapy with an intranasal corticosteroid and an intranasal antihistamine (e.g., azelastine) shows greater symptom reduction than either agent alone 1
• Cetirizine helps with rhinorrhea but has limited effectiveness for congestion compared to intranasal corticosteroids 1

Ipratropium Bromide Nasal Spray

• Effective specifically for rhinorrhea (runny nose)
• Minimal effect on congestion
• Safe cardiovascular profile with minimal systemic absorption 1

Short-Term Decongestants (Use with Caution)

Topical Nasal Decongestants

• Appropriate for short-term use only (generally ≤7 days) 2, 3
  • Oxymetazoline (Afrin)
  • Xylometazoline
  • Phenylephrine
• Provide rapid relief through nasal vasoconstriction 2, 3
• Warning: Regular use can lead to rebound nasal congestion (rhinitis medicamentosa) 2
• Recent research suggests no evidence of rhinitis medicamentosa with oxymetazoline when used at recommended doses for up to 7 days 4

Oral Decongestants

• Pseudoephedrine is effective for temporary relief of nasal congestion 5, 6
• Causes small increases in systolic blood pressure (0.99 mmHg) and heart rate (2.83 beats/min) 2
• Should be used with caution in patients with:
  • Hypertension (monitor blood pressure)
  • Arrhythmias
  • Coronary artery disease
  • Cerebrovascular disease
  • Hyperthyroidism 2
• Avoid in first trimester of pregnancy 2

Alternative Approaches

Mechanical Options

• External nasal dilator strips provide temporary symptomatic relief for mild to moderate nasal congestion 1

Environmental Management

• Implement allergen avoidance strategies based on identified triggers:
  • Air filtration systems
  • Bed covers for dust mite allergies
  • Pet removal if allergic
  • Acaricides for dust mite control 1

Treatment Algorithm

1. Start with: Intranasal corticosteroids + saline irrigation
2. If inadequate response after 2-4 weeks: Add second-generation antihistamine
3. For acute exacerbations: Consider short-term (≤7 days) topical decongestant
4. For severe congestion requiring immediate relief: Consider oral decongestant (pseudoephedrine) if no contraindications exist
5. For persistent symptoms despite optimal therapy: Consider referral to allergist/immunologist for possible allergen testing and immunotherapy 1

Important Precautions

• Avoid first-generation antihistamines due to sedation and anticholinergic effects 1
• Use oral decongestants cautiously in patients with cardiovascular conditions 2
• Limit topical decongestant use to prevent rhinitis medicamentosa 2
• Use topical vasoconstrictors with care in children under 1 year due to narrow therapeutic window 2
• Monitor blood pressure in patients using sympathomimetic medications 1
• Patients on anticoagulants should be aware of increased risk of epistaxis with intranasal medications 1

When to Refer

• Persistent symptoms despite optimal pharmacologic therapy
• Complications exist
• Treatment is ineffective after 2-4 weeks 1