What are the treatment options for nasal congestion?

Treatment of Nasal Congestion

Intranasal corticosteroids are the most effective first-line monotherapy for nasal congestion, with onset of action typically within 12 hours and maximum benefit achieved within 4-7 days. 1, 2

First-Line Treatment: Intranasal Corticosteroids

• Intranasal corticosteroids (such as fluticasone propionate) should be initiated as primary therapy for nasal congestion, particularly when associated with allergic or non-allergic rhinitis, as they are more effective than oral antihistamine-leukotriene receptor antagonist combinations. 3, 1

• The recommended starting dose for adults is 200 mcg daily (two 50-mcg sprays per nostril once daily), which can be administered as a single daily dose or divided into 100 mcg twice daily. 2

• For pediatric patients aged 4 years and older, initiate treatment with 100 mcg daily (one spray per nostril once daily), reserving 200 mcg daily for inadequate responders. 2

• Patients must understand that full therapeutic benefit may take up to 2 weeks, though symptom improvement often begins within 12 hours, and they should continue regular use rather than discontinuing prematurely. 3, 2

• Local side effects are minimal but include nasal irritation and epistaxis; nasal septal perforation is rare. 3

Short-Term Adjunctive Therapy: Topical Decongestants

• Topical nasal decongestants (oxymetazoline, xylometazoline) provide rapid relief and should be limited to 3-5 consecutive days maximum to prevent rhinitis medicamentosa (rebound congestion). 3, 1

• Recent evidence suggests that oxymetazoline used for up to 7 days (400 μg total daily dose) and xylometazoline for up to 10 days (840 μg total daily dose) do not cause rebound congestion when used at recommended dosing. 4

• Topical decongestants may facilitate delivery of intranasal corticosteroids when significant mucosal edema is present. 3

• If rhinitis medicamentosa develops, topical decongestants must be stopped immediately. 3, 5

Second-Line Options: Oral Decongestants

• Oral decongestants (pseudoephedrine, phenylephrine) reduce nasal congestion through systemic α-adrenergic agonism but cause side effects including insomnia, irritability, and palpitations. 3, 1

• Use oral decongestants with extreme caution in patients with cardiac arrhythmias, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism. 3

• Pseudoephedrine is associated with small increases in systolic blood pressure and heart rate. 1

• Oral decongestants should be avoided in older adults and young children due to increased risk of adverse effects. 3

Adjunctive Therapies

Nasal Saline Irrigation

• Nasal saline irrigation (buffered hypertonic 3-5% solution preferred) provides symptomatic relief with minimal adverse effects and may improve quality of life, particularly in patients with frequent sinusitis. 3, 1

• Saline irrigation is beneficial as monotherapy or combined with other treatments for chronic rhinosinusitis. 3

Intranasal Antihistamines

• Intranasal antihistamines (azelastine) are equal to or superior to oral second-generation antihistamines and have clinically significant effects on nasal congestion. 3

• Combining intranasal antihistamines with intranasal corticosteroids may provide additional benefit, particularly for mixed rhinitis, though the optimal interval between administrations is not established. 3, 1

Intranasal Anticholinergics

• Ipratropium bromide effectively reduces rhinorrhea but has no effect on nasal congestion or other nasal symptoms. 3, 1

• Concomitant use with intranasal corticosteroids is more effective for rhinorrhea than either agent alone without increased adverse events. 3

Oral Antihistamines

• Second-generation oral antihistamines (loratadine, fexofenadine, desloratadine) are less effective for nasal congestion compared to other nasal symptoms. 1

• Antihistamines have no role in symptomatic relief of acute bacterial rhinosinusitis in non-atopic patients and may worsen congestion by drying nasal mucosa. 3

• In allergic patients, antihistamines combined with oral decongestants provide more effective congestion relief than antihistamines alone. 3

Leukotriene Receptor Antagonists

• Oral leukotriene receptor antagonists (montelukast) have similar efficacy to oral antihistamines and may be particularly useful in patients with both rhinitis and asthma. 3, 1

Treatment Algorithm

For allergic rhinitis with congestion:

1. Start intranasal corticosteroids as first-line therapy (200 mcg daily for adults, 100 mcg daily for children ≥4 years). 1, 2
2. If immediate relief needed, add short-term topical decongestant (maximum 3-5 days). 1
3. If symptoms persist after 4-7 days, add intranasal antihistamine. 1
4. Consider oral decongestant if topical therapy contraindicated, with appropriate patient screening for contraindications. 1

For acute congestion (common cold, acute rhinosinusitis):

1. Short-term topical decongestant (3-5 days maximum) for rapid relief. 3, 1
2. Nasal saline irrigation for symptomatic relief. 3
3. Analgesics (NSAIDs, acetaminophen) for associated facial pain. 3
4. Avoid antihistamines in non-allergic patients as they provide no benefit and may worsen congestion. 3

For non-allergic rhinitis:

1. Intranasal corticosteroids remain effective for vasomotor rhinitis and NARES. 3
2. Ipratropium bromide specifically for rhinorrhea component. 3
3. Oral decongestants (pseudoephedrine) reduce nasal congestion in vasomotor rhinitis. 3

Critical Pitfalls to Avoid

• Never recommend prolonged use of topical decongestants beyond 3-5 days due to risk of rhinitis medicamentosa, though recent evidence suggests slightly longer durations may be safe at recommended doses. 3, 5, 4

• Do not prescribe first-generation antihistamines without counseling patients about sedation, performance impairment, and anticholinergic effects; second-generation agents are preferred. 3

• Avoid oral corticosteroids for routine nasal congestion; reserve short courses (5-7 days) only for very severe or intractable symptoms. 3

• Do not use antibiotics for symptomatic relief of nasal congestion in acute rhinosinusitis, as they do not improve congestion symptoms. 3