What are the treatment options for nasal congestion?

Treatment for Nasal Congestion

Intranasal corticosteroids are the most effective first-line treatment for nasal congestion, particularly when associated with allergic rhinitis, with onset of action within 12 hours and minimal side effects. 1

First-Line Treatment Algorithm

Start with intranasal corticosteroids as monotherapy for chronic or recurrent nasal congestion, as recommended by the American Academy of Allergy, Asthma, and Immunology—they are more effective than combination oral antihistamine plus leukotriene receptor antagonist therapy and work for all nasal symptoms including congestion. 1

For acute congestion requiring immediate relief (viral upper respiratory infections, acute sinusitis exacerbations):

• Use topical decongestants (oxymetazoline, phenylephrine) for maximum 3-5 days only to avoid rhinitis medicamentosa (rebound congestion). 2, 1
• Topical decongestants provide rapid relief through nasal vasoconstriction but rebound congestion may develop as early as day 3-4 of continuous use. 2

Critical pitfall: Regular use beyond 3-5 days causes rhinitis medicamentosa—treat this by stopping the topical decongestant immediately and using intranasal corticosteroids (plus short-course oral steroids if necessary) to hasten mucosal recovery. 2

Second-Line Options

When intranasal corticosteroids alone are insufficient:

• Add intranasal antihistamine to the corticosteroid for persistent symptoms. 1
• Oral pseudoephedrine (30-60 mg every 4-6 hours) is effective for congestion and significantly superior to oral phenylephrine due to better bioavailability. 1, 3, 4

Important cardiovascular considerations for oral decongestants: Pseudoephedrine increases systolic blood pressure by approximately 1 mmHg and heart rate by 2.83 beats/min—use with caution in patients with hypertension, arrhythmias, coronary artery disease, cerebrovascular disease, hyperthyroidism, or glaucoma. 3

Avoid oral phenylephrine as primary therapy—it undergoes extensive first-pass gut metabolism making it far less efficacious than pseudoephedrine despite being an α-adrenergic agonist. 3

Adjunctive Therapies

• Nasal saline irrigation provides symptomatic relief with minimal adverse effects and is particularly useful for drug-induced congestion. 1
• Leukotriene receptor antagonists (montelukast) have similar efficacy to oral antihistamines and are especially useful when both rhinitis and asthma coexist. 1
• Intranasal ipratropium reduces rhinorrhea but not congestion—can be combined with intranasal corticosteroids for enhanced rhinorrhea control. 1

Special Population Warnings

Pregnancy: Use decongestants with caution during first trimester due to reported fetal heart rate changes. 2, 1, 3

Children under 6 years: The American Academy of Pediatrics states that efficacy of OTC cough and cold medications has not been established in children younger than 6 years, and these should generally be avoided due to potential toxicity including 54 decongestant-related fatalities (43 under age 1 year) reported between 1969-2006. 2, 3

Infants under 1 year: Topical vasoconstrictors have a narrow therapeutic window with increased risk for cardiovascular and CNS toxicity—use with extreme care. 2, 1

Treatment Hierarchy Summary

1. Chronic/allergic congestion: Intranasal corticosteroids first-line 1
2. Acute congestion needing rapid relief: Topical decongestant for 3-5 days maximum 2, 1
3. Persistent symptoms: Add intranasal antihistamine to corticosteroid 1
4. When topical contraindicated: Oral pseudoephedrine (not phenylephrine) 1, 3
5. Adjunctive therapy: Nasal saline irrigation for all patients 1