What medication is recommended for treating congestion?

Treatment for Nasal Congestion

Intranasal corticosteroids are the most effective first-line medication for nasal congestion, particularly when associated with allergic rhinitis, with onset of action typically within 12 hours and superior efficacy compared to all other monotherapy options. 1

First-Line Therapy: Intranasal Corticosteroids

• Intranasal corticosteroids (such as fluticasone propionate) are recommended as initial treatment for nasal congestion because they effectively control all major symptoms including congestion, sneezing, itching, and rhinorrhea. 2, 1, 3

• These agents demonstrate superior efficacy compared to oral antihistamine-leukotriene antagonist combinations for seasonal and perennial allergic rhinitis. 2, 1

• Onset of action occurs within 12 hours in most patients, though full benefit may require several days to weeks of continuous use. 2, 1

• Local side effects are minimal when patients direct sprays away from the nasal septum, though nasal irritation and bleeding can occur if technique is improper. 2

• The nasal septum should be examined periodically for mucosal erosions, as these may indicate increased risk for septal perforation (though this complication is rare). 2

Short-Term Rapid Relief: Topical Decongestants

• Topical decongestants provide rapid relief and are appropriate for short-term use (maximum 3-5 days) for acute nasal congestion associated with viral infections, allergic rhinitis exacerbations, or eustachian tube dysfunction. 2, 1

• The critical limitation is rhinitis medicamentosa (rebound congestion), which can develop in some patients after as little as 3 days of regular use, though others may tolerate 4-6 weeks without rebound. 2

• Given this variability, instruct patients explicitly not to exceed 3-5 days of continuous use to minimize risk of medication-induced rhinitis. 2, 1, 4

• Topical decongestants may assist delivery of other intranasal medications when significant mucosal edema is present. 2

Second-Line Oral Therapy: Oral Decongestants

• Oral decongestants (pseudoephedrine 60 mg or phenylephrine) effectively reduce nasal congestion in both allergic and nonallergic rhinitis and provide benefit when combined with antihistamines. 2, 1, 5

• Pseudoephedrine demonstrates objective efficacy in reducing nasal airway resistance with both single and multiple doses. 6

• Common side effects include insomnia, appetite loss, irritability, palpitations, and small increases in systolic blood pressure and heart rate. 2, 1

• Use with caution in hypertensive patients (monitoring is advised), and exercise particular caution in patients with arrhythmias or coronary artery disease. 2, 1

• Avoid during first trimester of pregnancy due to reported fetal heart rate changes. 1

Combination Therapy Strategies

• When intranasal corticosteroids alone provide insufficient relief, adding an intranasal antihistamine is recommended as the next step. 1

• Oral antihistamine-decongestant combinations (such as desloratadine-pseudoephedrine) provide superior relief of nasal congestion compared to either component alone, particularly for patients with moderate-to-severe congestion. 7, 8

• Intranasal anticholinergics (ipratropium bromide) combined with intranasal corticosteroids effectively reduce rhinorrhea but have minimal effect on congestion itself. 2, 1

Adjunctive Options

• Nasal saline irrigation provides symptomatic relief with minimal adverse effects and is particularly useful for drug-induced nasal congestion. 1

• Leukotriene receptor antagonists have similar efficacy to oral antihistamines but are less effective than intranasal corticosteroids; consider in patients with concurrent asthma. 2, 1

• Second-generation oral antihistamines (loratadine, fexofenadine) are less effective for congestion than for other nasal symptoms and should not be used as monotherapy for congestion. 1

Critical Pitfalls to Avoid

• Never use topical decongestants beyond 3-5 days continuously to prevent rhinitis medicamentosa. 2, 1, 4

• Do not rely on first-generation antihistamines for congestion relief, as they are ineffective for nasal stuffiness when used alone. 9

• If rhinitis medicamentosa develops, immediately discontinue topical decongestants and transition to intranasal corticosteroids. 4

• Phenylephrine oral formulations have questionable efficacy due to extensive first-pass metabolism and lack of bioavailability at recommended doses. 9