What decongestants can be prescribed for patients with nasal congestion?

Decongestants for Nasal Congestion

Oral Decongestants

For patients requiring oral decongestant therapy, prescribe pseudoephedrine 60 mg every 4-6 hours (maximum 240 mg/day) as it is the only oral decongestant with proven efficacy, while phenylephrine should be avoided due to extensive first-pass metabolism rendering it ineffective at standard doses. 1, 2

Pseudoephedrine (Preferred Oral Agent)

• Pseudoephedrine is the only effective oral decongestant and reduces nasal congestion in both allergic and nonallergic rhinitis, with documented efficacy using objective measures of nasal airway resistance 1, 3
• Available as 30 mg or 60 mg immediate-release tablets, or 240 mg extended-release formulations for once-daily dosing 4, 5
• Provides significant improvement in nasal congestion within hours of dosing and maintains efficacy with multiple doses over several days 3
• Monitor blood pressure in hypertensive patients, though elevation is rarely noted in normotensive patients and only occasionally in those with controlled hypertension 1
• Use with extreme caution or avoid entirely in patients with arrhythmias, angina pectoris, coronary artery disease, cerebrovascular disease, and hyperthyroidism 1
• Common side effects include insomnia, loss of appetite, irritability, and palpitations, with heart rate increases of 2-4 beats per minute 1, 3
• Note that pseudoephedrine is kept behind the pharmacy counter due to methamphetamine production concerns, requiring patient identification for purchase 1

Phenylephrine (Not Recommended)

• Phenylephrine is extensively metabolized in the gut and lacks proven efficacy as an oral decongestant at currently available doses 1, 2
• Despite being unrestricted and substituted in many over-the-counter products, it should not be considered therapeutically equivalent to pseudoephedrine 1

Topical Decongestants

For rapid relief of severe nasal congestion, prescribe oxymetazoline 0.05% nasal spray (2 sprays per nostril twice daily) but strictly limit use to 3 days maximum to prevent rhinitis medicamentosa. 1, 6

Short-Term Use (3 Days Maximum)

• Topical decongestants (oxymetazoline, xylometazoline, phenylephrine) provide superior efficacy for nasal decongestion compared to intranasal corticosteroids, with onset within minutes 1, 7
• Appropriate indications include: acute bacterial or viral infections, exacerbations of allergic rhinitis, and eustachian tube dysfunction 1
• Critical warning: Rhinitis medicamentosa (rebound congestion) may develop as early as day 3 of regular use, though some patients tolerate 4-6 weeks without rebound 1
• Given this variability, instruct all patients about the risk of rhinitis medicamentosa when used beyond 3 days 1

Safety Considerations

• Generally well-tolerated with local effects (stinging, burning, sneezing, nasal dryness) 1
• Rare but serious cerebrovascular events reported include anterior ischemic optic neuropathy, stroke, branch retinal artery occlusion, and "thunderclap" vascular headache 1
• Use with caution during first trimester of pregnancy due to reported fetal heart rate changes 1, 6
• Use with care in children under 1 year due to narrow therapeutic window and increased risk of cardiovascular and CNS side effects 1, 6

Alternative First-Line Therapy

For patients requiring ongoing treatment of nasal congestion, particularly with allergic rhinitis, prescribe intranasal corticosteroids (fluticasone, mometasone, triamcinolone) as first-line therapy rather than decongestants. 1, 6, 7

• Intranasal corticosteroids are the most effective medication class for controlling all four major symptoms of allergic rhinitis, including nasal congestion 1
• Onset of action typically within 12 hours, with no risk of rebound congestion or cardiovascular effects 6, 7
• Can be initiated without prior trial of antihistamines or oral decongestants 1
• Minimal systemic side effects at recommended doses; instruct patients to direct sprays away from nasal septum to minimize local irritation and bleeding 1

Combination Therapy

• Oral decongestants are beneficial when combined with antihistamines for comprehensive symptom relief in allergic rhinitis 1, 8
• Desloratadine/pseudoephedrine combination provides significantly better relief of nasal congestion than either component alone, with improvements observed by day 2 8, 5
• Intranasal anticholinergics (ipratropium) combined with intranasal corticosteroids may provide increased efficacy without additional adverse effects, though primarily for rhinorrhea rather than congestion 1, 6

Special Population: Hypertensive Patients

In hypertensive patients, prioritize oxymetazoline nasal spray (limited to 3 days) or intranasal corticosteroids over oral pseudoephedrine. 7

• Oral pseudoephedrine causes measurable increases in systolic blood pressure and heart rate and should be used with extreme caution or avoided 7
• Nasal saline irrigation provides safe adjunctive therapy with no cardiovascular risks 6, 7
• Intranasal corticosteroids offer the most effective long-term option with no cardiovascular effects 7