What are the best treatments for a running nose and nasal congestion?

Treatment of Running Nose and Nasal Congestion

For acute nasal congestion and rhinorrhea, use intranasal corticosteroids as first-line therapy, with short-term topical decongestants (3-5 days maximum) for severe congestion, reserving oral pseudoephedrine for situations where topical agents are contraindicated. 1, 2

First-Line Treatment Approach

Intranasal Corticosteroids (Most Effective)

• Intranasal corticosteroids are the most effective monotherapy for both allergic and some forms of nonallergic rhinitis, controlling all nasal symptoms including congestion, rhinorrhea, sneezing, and nasal itch. 1
• These agents are effective for rhinorrhea and congestion with minimal systemic side effects when used at recommended doses. 1
• Onset of action typically occurs within 12 hours, though may start as early as 3-4 hours in some patients—less rapid than antihistamines but superior in overall efficacy. 1
• Can be used on an as-needed basis (>50% of days) for seasonal symptoms or continuously for perennial symptoms. 1

Nasal Saline Irrigation (Adjunctive)

• Nasal saline irrigation provides symptomatic relief, particularly in children, and is considered a safe adjunctive option for acute upper respiratory tract infections. 1

Decongestants for Severe Congestion

Topical Decongestants (Preferred for Short-Term Use)

• Topical decongestants like oxymetazoline or xylometazoline are superior to oral pseudoephedrine for reducing sinus and nasal mucosal congestion based on imaging studies. 2, 3
• Use only for 3-5 consecutive days maximum to avoid rhinitis medicamentosa (rebound congestion). 1, 2, 3
• Recent high-quality evidence suggests no rebound congestion occurs with oxymetazoline up to 7 days (400 μg total daily dose) or xylometazoline up to 10 days (840 μg total daily dose), though the traditional 3-5 day limit remains the guideline recommendation. 4
• Rebound congestion may develop as early as day 3-4 with regular use, creating paradoxical worsening of obstruction. 1, 3

Contraindications for topical decongestants: 1, 3

• First trimester pregnancy (fetal heart rate changes reported)
• Infants under 1 year (narrow therapeutic window, risk of cardiovascular/CNS toxicity)
• Use with caution in uncontrolled cardiovascular disease

Oral Decongestants (Second-Line for Congestion)

• Pseudoephedrine (60 mg every 4-6 hours) is significantly more effective than phenylephrine due to better oral bioavailability; phenylephrine undergoes extensive first-pass metabolism and should be avoided. 2, 5
• Oral decongestants have modest effects on nasal airway resistance in adults with common cold. 2
• Causes small increases in systolic blood pressure (0.99 mmHg) and heart rate (2.83 beats/min). 2

Screen for contraindications before prescribing: 2

• Hypertension, arrhythmias, coronary artery disease
• Cerebrovascular disease, hyperthyroidism, glaucoma
• First trimester pregnancy

Antihistamines: Role and Limitations

Second-Generation Oral Antihistamines

• Appropriate for allergic rhinitis only—generally ineffective for nonallergic rhinitis, making them poor choices for undifferentiated nasal congestion. 1
• Less effective for nasal congestion than other symptoms (rhinorrhea, sneezing, itch). 1
• Fexofenadine, loratadine, and desloratadine cause no sedation at recommended doses, unlike first-generation agents. 1
• Have limited short-term benefit (days 1-2) for common cold symptoms in adults, with no clinically significant effect on nasal obstruction. 1

Intranasal Antihistamines

• Intranasal azelastine has rapid onset of action and is equal or superior to oral second-generation antihistamines for allergic rhinitis. 1
• Has clinically significant effect on nasal congestion, though less effective than intranasal corticosteroids. 1
• Appropriate for mixed rhinitis (allergic + vasomotor). 1
• Side effects include bitter taste and somnolence. 1

Anticholinergics for Rhinorrhea

• Ipratropium bromide nasal spray specifically reduces rhinorrhea but has no effect on nasal congestion. 1
• Effective for rhinorrhea in both allergic rhinitis and nonallergic conditions including gustatory rhinitis. 1
• Combination with intranasal corticosteroid is more effective for rhinorrhea than either drug alone. 1
• Side effects are generally well-tolerated and self-limiting. 1

What NOT to Do

Avoid These Common Pitfalls:

• Do not use OTC cough and cold medications in children under 6 years—efficacy not established and potential for serious toxicity exists. 1
• Never use first-generation antihistamines for nonallergic rhinitis or common cold—they may worsen congestion by drying nasal mucosa and cause unperceived sedation with performance impairment. 1, 2
• Do not extend topical decongestant use beyond 5 days without a prolonged drug-free interval, despite emerging evidence suggesting longer use may be safe. 1, 3, 4
• Avoid phenylephrine as oral decongestant—poor bioavailability renders it ineffective. 2
• Do not use antibiotics for common cold or acute viral rhinitis—no benefit and risk of adverse effects. 1

Treatment Algorithm by Clinical Scenario

Acute Viral Upper Respiratory Infection (Common Cold):

1. Intranasal corticosteroids have no proven benefit for symptomatic relief from common cold. 1
2. For severe congestion: Short-term topical decongestant (3-5 days maximum). 1
3. Ipratropium bromide for bothersome rhinorrhea. 1
4. Paracetamol may help nasal obstruction and rhinorrhea but not other symptoms. 1

Allergic Rhinitis (Seasonal or Perennial):

1. Start with intranasal corticosteroid (most effective monotherapy). 1
2. Add short-term topical decongestant (3-5 days) if severe congestion present. 1
3. Consider second-generation oral antihistamine for additional symptom control, particularly for sneezing, itch, and rhinorrhea. 1
4. Ipratropium bromide if rhinorrhea is predominant symptom. 1

Nonallergic/Vasomotor Rhinitis:

1. Intranasal corticosteroids (effective for some forms including vasomotor rhinitis and NARES). 1
2. Intranasal azelastine (approved for vasomotor rhinitis). 1
3. Ipratropium bromide for rhinorrhea. 1
4. Avoid oral antihistamines—generally ineffective for nonallergic rhinitis. 1

Acute Bacterial Rhinosinusitis:

1. Systemic antibiotics as primary treatment. 2, 3
2. Intranasal corticosteroids and nasal saline irrigation for symptomatic relief. 2
3. Short-term topical decongestant (3-5 days) preferred over oral agents for severe congestion. 2
4. Oral pseudoephedrine if topical contraindicated, after screening for cardiovascular contraindications. 2