What are the treatments for nasal congestion?

Treatment of Nasal Congestion

Intranasal corticosteroids are the most effective first-line monotherapy for nasal congestion, with onset of action within 12 hours and superior efficacy compared to other single agents. 1

First-Line Treatment: Intranasal Corticosteroids

• Intranasal corticosteroids should be initiated as primary therapy for nasal congestion, regardless of whether the etiology is allergic rhinitis, viral rhinosinusitis, or acute bacterial rhinosinusitis. 2, 1
• These agents work by decreasing vascular permeability, inhibiting inflammatory cell infiltration (especially eosinophils), and reducing mucous secretagogue release. 2
• Fluticasone propionate can be dosed as 200 mcg once daily (two 50-mcg sprays per nostril) or 100 mcg twice daily (one 50-mcg spray per nostril twice daily), with no significant difference in efficacy between regimens. 3
• Maximum benefit may take several days to develop, though symptom improvement begins within 12 hours. 3
• Patients must be counseled to avoid spraying directly at the nasal septum to prevent local complications and to continue therapy for at least 2 weeks before assessing full benefit. 2

Adjunctive Therapy: Nasal Saline Irrigation

• Nasal saline irrigation should be recommended as adjunctive therapy for symptomatic relief with minimal risk of adverse effects. 2, 1
• Hypertonic saline improves mucociliary transit times more effectively than normal saline, though both provide benefit. 2
• This intervention is particularly useful in chronic rhinosinusitis and can be used safely alongside other therapies. 2

Short-Term Rescue: Topical Decongestants

• Topical decongestants (oxymetazoline, xylometazoline) provide rapid, superior relief but must be strictly limited to 3-5 days maximum to prevent rhinitis medicamentosa (rebound congestion). 1, 4, 5
• These agents cause direct vasoconstriction and decreased nasal edema through α-adrenergic receptor activation. 2
• Prolonged use beyond 5 days leads to drug-induced rhinitis, which requires immediate cessation of the topical decongestant. 2, 5
• Topical decongestants should be used with caution in children under 1 year due to narrow therapeutic window. 1

Oral Decongestants: Context-Specific Use

For Post-Viral Nasal Congestion:

• First-generation antihistamine/decongestant combinations are first-line therapy for post-viral nasal congestion, with improvement expected within days to 2 weeks. 4
• Recommended regimens include dexbrompheniramine 6 mg plus pseudoephedrine 120 mg (sustained-release), both twice daily. 4
• The benefit derives from anticholinergic properties of first-generation antihistamines, not antihistamine action. 4

For Allergic Rhinitis:

• Oral decongestants like pseudoephedrine effectively reduce congestion but are associated with small increases in systolic blood pressure and heart rate. 1
• Pseudoephedrine is significantly more effective than phenylephrine due to superior oral bioavailability. 4

Critical Safety Contraindications:

• Oral decongestants must be avoided or used with extreme caution in patients with:
  • Cardiac arrhythmias, angina pectoris, or coronary artery disease 1, 4
  • Cerebrovascular disease or history of stroke 4
  • Uncontrolled hypertension, hyperthyroidism, or glaucoma 4
  • First trimester of pregnancy (due to reported fetal heart rate changes) 1, 4

Analgesics for Symptomatic Relief

• Acetaminophen or ibuprofen may be recommended for pain and fever relief associated with acute bacterial rhinosinusitis or viral rhinosinusitis. 2

Ineffective or Contraindicated Therapies

• Second-generation oral antihistamines alone (loratadine, fexofenadine) are less effective for nasal congestion than for other nasal symptoms and should not be used as monotherapy for congestion. 1, 4
• Antihistamines without decongestants may worsen symptoms by drying nasal mucosa in non-allergic patients. 4
• Over-the-counter cough and cold medications should be avoided in children under 6 years due to lack of established efficacy and potential toxicity. 4
• Phenylpropanolamine has been withdrawn from all over-the-counter products due to risk of hemorrhagic stroke in women. 2

Treatment Algorithm by Clinical Context

Allergic Rhinitis with Congestion:

1. Start intranasal corticosteroid (fluticasone 200 mcg once daily) 1, 3
2. Add nasal saline irrigation for additional symptomatic relief 1
3. If inadequate response after 2 weeks, add intranasal antihistamine 1
4. Consider short-term topical decongestant (≤3-5 days) for severe acute exacerbations 1

Viral or Acute Bacterial Rhinosinusitis:

1. Intranasal corticosteroid plus nasal saline irrigation 2
2. Analgesics (acetaminophen or ibuprofen) for pain/fever 2
3. Short-term topical decongestant (≤3-5 days) if severe congestion 4

Post-Viral Nasal Congestion:

1. First-generation antihistamine/decongestant combination (if no contraindications) 4
2. Short-term topical decongestant (≤3-5 days) for rapid relief 4
3. Avoid second-generation antihistamines alone 4

Common Pitfalls to Avoid

• Failing to counsel patients that intranasal corticosteroids require 2 weeks for full benefit, leading to premature discontinuation. 2
• Allowing topical decongestant use beyond 5 days, which inevitably causes rhinitis medicamentosa requiring more difficult management. 2, 4, 5
• Prescribing oral decongestants without screening for cardiovascular contraindications. 1, 4
• Using second-generation antihistamines as monotherapy for congestion when they are ineffective for this specific symptom. 4