What over-the-counter (OTC) medications are recommended for treating sinus congestion?

OTC Medications for Sinus Congestion

For sinus congestion, pseudoephedrine (Sudafed) is the most effective oral decongestant available over-the-counter, while intranasal corticosteroids like fluticasone (Flonase) provide superior overall symptom control for congestion lasting more than a few days. 1, 2

First-Line Options Based on Duration and Severity

For Acute, Short-Term Relief (≤3 days)

• Topical nasal decongestants (oxymetazoline/Afrin) provide the most rapid relief, working within minutes with minimal systemic effects 1, 3
• These are appropriate for acute viral infections, sinusitis exacerbations, and Eustachian tube dysfunction 1, 3
• Critical warning: Never use topical decongestants beyond 3 days due to risk of rhinitis medicamentosa (rebound congestion), though some patients develop this as early as 3 days while others tolerate 4-6 weeks 1

For Ongoing Congestion (>3 days)

• Intranasal corticosteroids (fluticasone, mometasone) are the most effective medication class for controlling nasal congestion and should be considered before oral decongestants 1, 4
• These work by reducing inflammatory cell infiltration and vascular permeability, providing superior symptom control compared to oral decongestants alone 1
• Patients must direct sprays away from the nasal septum to minimize risk of irritation and bleeding 1

Oral Decongestants

• Pseudoephedrine (30-60 mg every 4-6 hours) is significantly more effective than phenylephrine due to better oral bioavailability 1, 2, 5
• Phenylephrine is extensively metabolized in the gut and its efficacy as an oral decongestant has not been well established 1, 2
• Pseudoephedrine provides objective improvement in nasal airway resistance and subjective congestion scores in both single and multiple-dose studies 6

Safety Considerations and Contraindications

Cardiovascular Concerns

• Pseudoephedrine causes small increases in systolic blood pressure (0.99 mmHg) and heart rate (2.83 beats/min) through α-adrenergic vasoconstriction 3, 2
• Blood pressure elevation is very rarely noted in normotensive patients and only occasionally in those with controlled hypertension 1
• Use with extreme caution in patients with hypertension, arrhythmias, coronary artery disease, cerebrovascular disease, hyperthyroidism, or closed-angle glaucoma 1, 2
• For patients with controlled hypertension requiring decongestant therapy, topical oxymetazoline for ≤3 days is safer than oral pseudoephedrine 3
• Never combine oral and topical decongestants due to risk of hypertensive crisis from combined vasoconstrictive effects 3

Pediatric Use

• Oral decongestants are well tolerated in children over 6 years when used at appropriate doses 1
• Avoid in children under 6 years due to reports of agitated psychosis, ataxia, hallucinations, and even death 1, 2

Drug Interactions

• Concomitant use with caffeine, stimulants (ADHD medications), or other sympathomimetics increases risk of adverse events 1, 3

Combination Therapy Considerations

• The efficacy of combining oral decongestants with antihistamines has not been adequately documented to increase efficacy beyond either drug alone 1
• For allergic rhinitis with congestion, intranasal corticosteroids are more efficacious than combining an antihistamine with an oral decongestant 1
• Antihistamines alone have little objective effect on nasal congestion, though second-generation agents like desloratadine may provide modest benefit 1, 7

Practical Algorithm

1. Day 1-3 of acute congestion: Topical oxymetazoline (Afrin) for rapid relief 3
2. Beyond day 3: Switch to intranasal corticosteroid (fluticasone) as primary therapy 1, 4
3. If additional relief needed: Add pseudoephedrine (not phenylephrine) for short-term use 1, 2
4. For patients with cardiovascular disease: Prioritize intranasal corticosteroids; avoid oral decongestants if possible 3
5. Monitor blood pressure in hypertensive patients receiving any decongestant therapy 1, 3