What is the best course of treatment for a patient taking methotrexate (MTX) who presents with symptoms of a runny nose and sinus congestion?

Treatment of Runny Nose and Sinus Congestion in Patients on Methotrexate

For a patient on methotrexate presenting with runny nose and sinus congestion, treat as you would any patient with these symptoms—methotrexate does not contraindicate standard rhinitis therapies, and the key is distinguishing between viral rhinosinusitis, allergic rhinitis, and vasomotor rhinitis to guide treatment. 1

Initial Diagnostic Approach

Determine the underlying cause based on symptom duration and characteristics:

• If symptoms present for <10 days without worsening: This is acute viral rhinosinusitis and does NOT require antibiotics 1, 2
• If symptoms include clear rhinorrhea, nasal itching, sneezing, and watery eyes: This suggests allergic rhinitis 1, 3
• If symptoms are primarily nasal congestion and postnasal drainage without itching: This suggests vasomotor (nonallergic) rhinitis 1, 3

The physical examination should specifically assess for pale, edematous nasal turbinates (suggesting allergic rhinitis) versus erythematous, inflamed turbinates (suggesting viral or nonallergic causes) 1, 3

Treatment Based on Diagnosis

For Acute Viral Rhinosinusitis (Symptoms <10 Days)

Use topical nasal decongestants for rapid symptom relief, strictly limited to 3-5 days maximum:

• Oxymetazoline or xylometazoline nasal spray provides superior congestion relief compared to oral decongestants 2
• Critical warning: Exceeding 3-5 days of use causes rhinitis medicamentosa (rebound congestion), which worsens the underlying problem 2, 4
• Add nasal saline irrigation with buffered hypertonic saline for additional symptom improvement 2
• Use over-the-counter NSAIDs or acetaminophen for facial pain or headache 2

For Allergic Rhinitis

Start with intranasal corticosteroids as first-line therapy for moderate-to-severe symptoms:

• Fluticasone, mometasone, budesonide, or triamcinolone are all effective options 1, 3, 5
• Instruct patients to direct sprays away from the nasal septum to minimize irritation and bleeding 6
• These must be used daily at regular intervals, not as-needed, for optimal effect 6
• Intranasal corticosteroids are the most effective medication class for controlling all nasal symptoms, especially congestion 6, 5

For patients with prominent sneezing, itching, and rhinorrhea, add or use oral second-generation antihistamines:

• Cetirizine, loratadine, fexofenadine, or desloratadine are appropriate choices 1, 3
• Note that oral antihistamines have minimal effect on nasal congestion specifically 7

If congestion remains inadequately controlled after 2-4 weeks, add intranasal antihistamine:

• Azelastine provides rapid onset relief and works through a different mechanism than intranasal corticosteroids 7, 6
• The combination of intranasal corticosteroid plus intranasal antihistamine provides superior symptom reduction (37.9% vs 29.1% for intranasal corticosteroid alone) 6
• Common side effects include bitter taste and mild somnolence, but these are generally well-tolerated 7

For Vasomotor (Nonallergic) Rhinitis

Use intranasal antihistamine as first-line monotherapy:

• Azelastine or olopatadine are effective for both allergic and vasomotor rhinitis 7, 3
• Oral antihistamines are NOT effective for nonallergic rhinitis 1
• Intranasal corticosteroids can be added if symptoms persist 1

Methotrexate-Specific Considerations

There is NO contraindication to using standard rhinitis therapies in patients on methotrexate, with one important exception:

• Avoid trimethoprim-sulfamethoxazole at treatment doses (800mg/160mg twice daily) when used concurrently with methotrexate due to potential drug interaction and increased toxicity risk 1
• The lower dose used for Pneumocystis prophylaxis is generally tolerated but should be monitored 1
• All other rhinitis medications (intranasal corticosteroids, antihistamines, decongestants) have no interaction with methotrexate 1

Be vigilant for methotrexate-induced pneumonitis if respiratory symptoms develop:

• Methotrexate pneumonitis presents with fever, dyspnea, hypoxemia, and dry cough—distinct from simple rhinitis 8
• This is a rare but serious complication that requires immediate evaluation if suspected 1, 8
• Simple nasal congestion and rhinorrhea without lower respiratory symptoms do NOT suggest methotrexate toxicity 8

When to Escalate Care

Refer to allergist/immunologist if:

• Symptoms persist despite optimal pharmacotherapy after 2-4 weeks 1, 6
• Patient requires multiple costly medications over prolonged periods 1
• Symptoms significantly impair quality of life or work/school performance 1
• Allergen immunotherapy may be indicated for long-term disease modification 7

Consider bacterial sinusitis requiring antibiotics only if:

• Symptoms persist ≥10 days without improvement, OR 1, 2
• Severe symptoms with high fever (≥39°C) and purulent nasal discharge for ≥3-4 consecutive days 1