What medications are recommended for treating sinus congestion?

Medications for Sinus Congestion

For sinus congestion, use intranasal corticosteroids and nasal saline irrigation as first-line therapy, with short-term topical decongestants (3-5 days maximum) for severe acute congestion, reserving oral pseudoephedrine only for patients who cannot use topical agents. 1

First-Line Symptomatic Relief

Intranasal corticosteroids, nasal saline irrigation, and analgesics are the recommended initial treatments for both viral and bacterial rhinosinusitis. 2 These options provide symptomatic relief with minimal side effects:

• Nasal saline irrigation effectively removes mucus and relieves symptoms without cardiovascular risks or drug interactions. 2, 3
• Intranasal corticosteroids (fluticasone, triamcinolone) are the most effective long-term option for chronic or recurrent congestion, with no rebound congestion risk and no cardiovascular effects. 3 However, benefits may take up to 15 days to manifest, with a modest effect size (number needed to treat = 14). 2
• Analgesics (acetaminophen or ibuprofen) relieve sinus pain, pressure, and fever without affecting blood pressure. 2, 3

Decongestants for Acute Severe Congestion

Topical Decongestants (Preferred)

Topical decongestants are superior to oral agents for acute severe nasal congestion:

• Oxymetazoline 0.05% nasal spray is the preferred first-line over-the-counter option, providing rapid relief within minutes without significant systemic blood pressure elevation. 3
• Xylometazoline nasal spray is superior to oral pseudoephedrine based on imaging studies showing reduced congestion of sinus and nasal mucosa. 1
• Critical limitation: Must not be used for more than 3-5 consecutive days due to rebound congestion and rhinitis medicamentosa. 2, 1

Oral Decongestants (Second-Line)

If topical decongestants are contraindicated or patient preference dictates:

• Pseudoephedrine 60 mg every 4-6 hours is the only effective oral decongestant, with proven efficacy in reducing nasal airway resistance. 1, 4, 5
• Phenylephrine should be avoided as an oral decongestant due to extensive first-pass metabolism in the gut, resulting in poor bioavailability and questionable efficacy. 2, 1

Contraindications and Precautions for Oral Decongestants

Screen carefully before prescribing oral pseudoephedrine:

• Cardiovascular contraindications: Use with extreme caution or avoid in hypertension, arrhythmias, coronary artery disease, and cerebrovascular disease, as pseudoephedrine causes measurable increases in systolic blood pressure (0.99 mmHg) and heart rate (2.83 beats/min). 2, 1, 3
• Other contraindications: Hyperthyroidism, closed-angle glaucoma, bladder neck obstruction. 2
• Pregnancy: Avoid during the first trimester due to reported fetal heart rate changes. 1
• Drug interactions: Concomitant use with caffeine and stimulants (e.g., ADHD medications) may increase adverse events. 2
• Pediatric caution: Use in children under 6 years has been associated with agitated psychosis, ataxia, hallucinations, and death. 2

What NOT to Use

• Antihistamines have no role in symptomatic relief of acute bacterial rhinosinusitis in non-allergic patients and may worsen congestion by drying nasal mucosa. 1
• Oral steroids should not be used routinely as they have side effects without proven benefit for symptom relief. 2
• Guaifenesin has no evidence supporting its effect on symptomatic relief of acute bacterial rhinosinusitis. 1

Clinical Algorithm

1. Start with intranasal corticosteroids and nasal saline irrigation for all patients with sinus congestion. 2, 1
2. Add analgesics (acetaminophen or ibuprofen) for pain and fever. 2
3. For severe acute congestion: Add topical decongestant (oxymetazoline or xylometazoline) for 3-5 days maximum. 1, 3
4. If topical agents contraindicated or refused: Consider oral pseudoephedrine 60 mg every 4-6 hours after screening for cardiovascular contraindications. 1, 4
5. Avoid phenylephrine, antihistamines (in non-allergic patients), and prolonged decongestant use. 2, 1

Common Pitfalls

• Rebound congestion from prolonged topical decongestant use (>3-5 days) is a frequent and avoidable complication. 2, 1
• Assuming phenylephrine is safer or equally effective to pseudoephedrine is incorrect; it has poor oral bioavailability and limited efficacy. 2, 1
• Prescribing antihistamines for non-allergic rhinosinusitis provides no benefit and may worsen symptoms. 1
• Failing to screen for cardiovascular disease before prescribing oral pseudoephedrine can lead to serious adverse events. 2, 3