What is the best medicine for nasal congestion and rhinitis?

Best Medicine for Nasal Congestion and Rhinitis

Intranasal corticosteroids are the most effective first-line treatment for nasal congestion and rhinitis, with fluticasone propionate or mometasone furoate as preferred agents. 1, 2

First-Line Treatment: Intranasal Corticosteroids

Start with intranasal corticosteroids as monotherapy for all patients with moderate-to-severe symptoms or when nasal congestion is prominent. 1, 2

Specific Dosing Recommendations

• Adults and children ≥12 years: Fluticasone propionate 2 sprays (100 mcg) per nostril once daily, or mometasone furoate 200 mcg twice daily 3, 4
• Children 4-11 years: Fluticasone propionate 1 spray (50 mcg) per nostril once daily (maximum 2 months per year before consulting physician) 4

Why Intranasal Corticosteroids Are Superior

• Most effective for nasal congestion compared to all other medication classes, including oral antihistamines, leukotriene antagonists, and their combinations 1, 2
• Relieves all symptoms: congestion, rhinorrhea, sneezing, itchy nose, and itchy/watery eyes 1, 4
• Onset of action: Usually within 12 hours, though full benefit may take several days to weeks 1, 2
• Minimal systemic effects when used at recommended doses, with no clinically significant hypothalamic-pituitary-adrenal axis suppression 3, 5

Critical Administration Technique

Direct the spray away from the nasal septum toward the lateral nasal wall to prevent septal irritation and rare perforation (occurs in <5% of patients). 1, 3

Second-Line and Adjunctive Treatments

For Rapid Relief (Acute Situations)

Topical decongestants (oxymetazoline, phenylephrine) provide immediate relief but limit use to 3-5 days maximum to avoid rhinitis medicamentosa. 2, 6

• Use only for short-term or episodic therapy 1, 2
• May assist intranasal corticosteroid delivery when severe mucosal edema is present 1

If Intranasal Corticosteroids Alone Are Insufficient

Add intranasal antihistamine (azelastine or olopatadine) to the intranasal corticosteroid for enhanced symptom control, particularly for mixed rhinitis. 1, 2

• Intranasal antihistamines have rapid onset (appropriate for as-needed use) and are equal or superior to oral antihistamines 1, 7
• Combination therapy is more effective than either agent alone for mixed rhinitis 1

Oral Medications (Less Effective for Congestion)

Oral antihistamines (cetirizine, fexofenadine, loratadine) are less effective for nasal congestion than intranasal corticosteroids but may be used for mild intermittent symptoms. 1, 7

• Second-generation agents preferred to avoid sedation and performance impairment 1
• Consider for patients with mild symptoms or those who prefer oral therapy 7

Oral decongestants (pseudoephedrine) reduce congestion but have cardiovascular side effects (increased blood pressure, heart rate). 2

• Use with caution in patients with hypertension, arrhythmias, or coronary artery disease 2
• Avoid during first trimester of pregnancy 2

Treatment Algorithm

1. Start intranasal corticosteroid (fluticasone propionate or mometasone furoate) as first-line monotherapy 1, 2, 3
2. If congestion persists after 1-2 weeks, add intranasal antihistamine 1, 2
3. For acute severe congestion, consider short-term (3-5 days) topical decongestant while initiating intranasal corticosteroid 2, 6
4. For rhinorrhea-predominant symptoms, add ipratropium bromide nasal spray to intranasal corticosteroid 1

Common Pitfalls to Avoid

• Do not use topical decongestants beyond 3-5 days due to rebound congestion (rhinitis medicamentosa) 2, 6
• Do not rely on oral antihistamines alone for significant nasal congestion—they are less effective than intranasal corticosteroids 1, 8
• Ensure patients continue intranasal corticosteroids daily during allergen exposure periods, even when symptoms improve 4
• In children 4-11 years, limit fluticasone use to 2 months per year before consulting a physician due to potential growth effects 4

Special Populations

Post-Viral Rhinosinusitis

Fluticasone propionate 50 mcg per nostril twice daily combined with antibiotics significantly improves cure rates and symptom scores compared to antibiotics alone in children. 1

Nonallergic Rhinitis

Intranasal antihistamine (azelastine) as monotherapy or combined with intranasal corticosteroid is more effective than intranasal corticosteroid alone for vasomotor rhinitis. 1