What are the treatment options for nasal congestion?

Treatment Options for Nasal Congestion

Intranasal corticosteroids are the most effective first-line treatment for nasal congestion, particularly in allergic rhinitis, with onset of action within 12 hours and no risk of rebound congestion. 1, 2

First-Line Treatment: Intranasal Corticosteroids

• Intranasal corticosteroids (fluticasone, mometasone) should be your primary choice for chronic or recurrent nasal congestion, as they are more effective than oral antihistamine-decongestant combinations and work through anti-inflammatory mechanisms rather than vasoconstriction. 1, 2

• These agents control all four major symptoms of allergic rhinitis, including nasal congestion, with minimal side effects and no risk of rhinitis medicamentosa. 1, 2

• Dosing for fluticasone propionate is 2 sprays per nostril once daily for adults, with onset of symptom relief typically within 12 hours. 1, 3

• Direct the spray away from the nasal septum to minimize irritation and bleeding risk. 3

Acute Congestion: Topical Decongestants (Short-Term Only)

• For rapid relief of severe acute congestion, use oxymetazoline 0.05% nasal spray, but strictly limit use to 3-5 days maximum to prevent rhinitis medicamentosa (rebound congestion). 1, 2, 3

• Topical decongestants provide symptom relief within minutes through nasal vasoconstriction and are superior to oral decongestants for immediate decongestion. 1, 2

• Critical pitfall: Rebound congestion can develop as early as the third or fourth day of continuous use, creating a cycle of worsening obstruction and increasing medication dependence. 2, 3

• For severe congestion while initiating intranasal corticosteroid therapy, you can safely combine oxymetazoline with intranasal corticosteroids for 2-4 weeks without causing rebound congestion—apply oxymetazoline first, wait 5 minutes, then apply the corticosteroid. 2, 3

Oral Decongestants (Alternative When Topical Contraindicated)

• Pseudoephedrine 60 mg every 4-6 hours is the only oral decongestant with proven efficacy; phenylephrine should be avoided due to extensive first-pass metabolism rendering it ineffective at standard doses. 4, 1

• Pseudoephedrine effectively reduces nasal congestion in both allergic and nonallergic rhinitis but causes small increases in systolic blood pressure and heart rate. 4, 1

• Use with extreme caution or avoid entirely in patients with arrhythmias, angina pectoris, coronary artery disease, cerebrovascular disease, hyperthyroidism, closed-angle glaucoma, and bladder neck obstruction. 4, 1

• Monitor blood pressure in hypertensive patients, though elevation is rarely noted in normotensive patients and only occasionally in those with controlled hypertension. 4, 1

• Oral decongestants are well tolerated in children over 6 years but have been associated with agitated psychosis, ataxia, hallucinations, and death in infants and young children—carefully weigh risks and benefits before use in children below age 6 years. 4

Combination Therapy for Allergic Rhinitis

• Oral antihistamine plus oral decongestant combinations (such as desloratadine/pseudoephedrine) control allergic rhinitis symptoms better than either agent alone, making this the preferred oral approach when nasal sprays are not tolerated. 2, 5

• However, combining intranasal corticosteroids with oral antihistamines as initial therapy offers no significant benefit over intranasal corticosteroids alone. 2

• For inadequate response to intranasal corticosteroids, add an intranasal antihistamine (azelastine) rather than an oral antihistamine. 1, 2

Intranasal Antihistamines

• Azelastine nasal spray is indicated for seasonal allergic rhinitis in adults and children 5 years and older, and for vasomotor rhinitis (including nasal congestion) in adults and children 12 years and older. 6

• Azelastine provides symptom relief within 3 hours and can be combined with intranasal corticosteroids for enhanced efficacy. 6

Adjunctive Therapy

• Nasal saline irrigation provides symptomatic relief with minimal risk of adverse effects and is particularly useful as an adjunct to other therapies. 1, 2

• Leukotriene receptor antagonists (montelukast) have similar efficacy to oral antihistamines and may be considered in patients with both rhinitis and asthma. 1

• Intranasal anticholinergics (ipratropium bromide) reduce rhinorrhea but not congestion, and can be combined with intranasal corticosteroids for enhanced effect on rhinorrhea. 1

Treatment Algorithm

For acute congestion (common cold, acute sinusitis):

1. First choice: Topical oxymetazoline for ≤3-5 days 2
2. Alternative if topical contraindicated: Oral pseudoephedrine 2
3. Adjunct: Nasal saline irrigation 2

For allergic rhinitis with congestion:

1. First-line: Intranasal corticosteroid 1, 2
2. If inadequate response: Add intranasal antihistamine 1, 2
3. For severe obstruction while starting therapy: Short-term topical oxymetazoline (≤3-5 days) 2
4. If nasal sprays not tolerated: Oral antihistamine plus oral decongestant combination 2

For chronic/vasomotor rhinitis:

1. First-line: Intranasal corticosteroid 2
2. Consider: Azelastine for vasomotor rhinitis in patients ≥12 years 6

Special Populations

• Pregnancy: Use decongestants with caution during the first trimester due to reported fetal heart rate changes. 1, 2

• Children: Topical decongestants should be avoided in children under 4 years and used with extreme caution in children under 1 year due to narrow therapeutic window and increased risk of cardiovascular and CNS side effects. 2, 3

• Hypertensive patients: Oral decongestants require blood pressure monitoring, though significant elevation is uncommon in controlled hypertension. 4, 1

Critical Pitfalls to Avoid

• Never recommend antihistamines alone for nasal congestion in non-allergic patients—they are ineffective and may worsen symptoms. 2

• Never continue topical decongestants beyond 3-5 days—this leads to rhinitis medicamentosa requiring weeks of treatment to resolve. 1, 2, 3

• Never restart topical decongestants if rhinitis medicamentosa develops—immediately discontinue and start intranasal corticosteroids, considering a short course of oral corticosteroids for severe cases. 2, 3

• Avoid phenylephrine as an oral decongestant—it lacks proven efficacy due to extensive first-pass metabolism. 4, 1