What is the best medication and dosage for adult nasal congestion?

Best Medication for Adult Nasal Congestion

For adult nasal congestion, oral decongestants (pseudoephedrine 60 mg every 4-6 hours or phenylephrine) are the most effective first-line treatment, with combination antihistamine-decongestant therapy providing superior relief when multiple symptoms are present. 1

Primary Treatment Options

Oral Decongestants (First-Line for Isolated Congestion)

Pseudoephedrine is the preferred oral decongestant with proven efficacy for nasal congestion relief. 1, 2

• Dosage: 60 mg every 4-6 hours (maximum 240 mg/day) 2
• Provides significant reduction in nasal airway resistance within hours of administration 2
• Safe for short-term use in normotensive adults with minimal blood pressure elevation 1
• Alternative: Phenylephrine (though pseudoephedrine shows superior efficacy) 1

Important precautions: 1

• Use with caution in patients with hypertension, cardiac arrhythmia, angina, cerebrovascular disease, bladder neck obstruction, glaucoma, or hyperthyroidism
• Monitor blood pressure in hypertensive patients
• May cause insomnia, irritability, palpitations, and loss of appetite
• Avoid concurrent use with caffeine (additive effects)

Combination Therapy (Superior for Multiple Symptoms)

Antihistamine-decongestant combinations provide greater overall symptom relief than monotherapy and are particularly effective when congestion accompanies other rhinitis symptoms. 1

Recommended combination: Desloratadine 5 mg + Pseudoephedrine 240 mg once daily 3, 4

• Significantly reduces nasal congestion scores by day 2 compared to either component alone 3, 4
• Provides full 24-hour coverage 4
• Second-generation antihistamine component avoids sedation and performance impairment 1

Alternative combinations include other second-generation antihistamines (cetirizine, loratadine, fexofenadine) with pseudoephedrine 1

Topical Nasal Decongestants (Short-Term Only)

Topical decongestants (oxymetazoline, xylometazoline) provide rapid relief but MUST be limited to 3 days maximum to prevent rhinitis medicamentosa. 1

• Use only for severe acute congestion or to facilitate delivery of other nasal medications 1
• Critical warning: Risk of rebound congestion (rhinitis medicamentosa) develops as early as 3 days with regular use 1
• If rhinitis medicamentosa occurs, discontinue immediately 5

When Congestion is Part of Allergic Rhinitis

Intranasal corticosteroids are the most effective medication class for allergic rhinitis with congestion, superior to all other monotherapies. 1

• Examples: Fluticasone, mometasone, budesonide (2 sprays per nostril daily)
• Onset within 12 hours, full benefit may take several days to weeks 1
• Direct spray away from nasal septum to minimize bleeding risk 1
• Can be combined with intranasal antihistamine (azelastine) for enhanced effect in severe cases 1

Medications with Limited Efficacy for Congestion

Avoid these for isolated nasal congestion: 1

• Oral antihistamines alone: minimal objective effect on congestion 1
• Nasal corticosteroids for common cold: not effective 1
• Antihistamines for non-allergic congestion: no benefit 1

Sample Prescription

For Acute Nasal Congestion (Common Cold/URI):

Rx: Pseudoephedrine 60 mg tablets
Sig: Take 1 tablet by mouth every 4-6 hours as needed for nasal congestion
Disp: #20 tablets
Refills: 0
Duration: Do not use for more than 7 days

For Moderate-to-Severe Congestion with Multiple Symptoms:

Rx: Desloratadine 5 mg/Pseudoephedrine 240 mg extended-release tablets
Sig: Take 1 tablet by mouth once daily
Disp: #15 tablets
Refills: 0
Duration: 15 days maximum for acute symptoms

For Severe Acute Congestion (Short-Term Rescue):

Rx: Oxymetazoline 0.05% nasal spray
Sig: Spray 2-3 sprays in each nostril twice daily
Disp: 1 bottle (15 mL)
Refills: 0
WARNING ON LABEL: "DO NOT USE FOR MORE THAN 3 DAYS. Risk of rebound congestion with prolonged use."

Clinical Pearls

• Combination antihistamine-decongestant-analgesic products have general benefit for common cold in adults 1
• Paracetamol (acetaminophen) may provide modest additional relief for nasal obstruction when combined with decongestants 1
• Nasal saline irrigation can be used adjunctively for symptomatic relief 1
• For patients with hypertension on controlled medication, oral decongestants can be used with monitoring, as blood pressure elevation is only occasional 1