What are the best medications for a generally healthy adult patient with nasal congestion due to a common cold?

Best Medications for Nasal Congestion from Common Cold

For nasal congestion due to the common cold in healthy adults, oral or topical decongestants are the first-line treatment, with topical agents (oxymetazoline, xylometazoline) providing faster relief but strictly limited to 3-5 days maximum to prevent rebound congestion. 1

First-Line Treatment: Decongestants

Topical Nasal Decongestants (Preferred for Rapid Relief)

• Oxymetazoline 0.05% nasal spray provides the fastest symptom relief, working within minutes, but must be limited to 3-5 consecutive days maximum to avoid rhinitis medicamentosa (rebound congestion). 1, 2
• Topical agents like xylometazoline work more rapidly than oral decongestants and are superior to oral pseudoephedrine for immediate congestion relief. 3
• Critical safety warning: Never exceed 5 days of continuous use as this causes worsening rebound congestion that is harder to treat than the original cold. 1, 3

Oral Decongestants (For Sustained Relief)

• Pseudoephedrine 60 mg every 4-6 hours provides modest but statistically significant relief (approximately 4-6% improvement) over 3-5 days with multiple doses. 1, 4
• Oral decongestants show objective improvement in nasal airway resistance and subjective congestion scores, with effects lasting several hours per dose. 5, 6
• Pseudoephedrine causes minimal adverse effects in adults—primarily a 2-4 beats per minute increase in heart rate—with no significant increase in overall adverse events compared to placebo. 5, 7

Adjunctive Symptomatic Measures

For Nasal Congestion Specifically

• Paracetamol (acetaminophen) 500-1000 mg every 4-6 hours may help relieve nasal obstruction and rhinorrhea specifically, though it doesn't improve other cold symptoms like sore throat or cough. 3, 1
• Nasal saline irrigation with buffered hypertonic saline (3-5%) has superior anti-inflammatory effects compared to isotonic saline and may provide modest symptom relief. 3, 1

For Rhinorrhea (Runny Nose) Only

• Ipratropium bromide nasal spray is effective specifically for rhinorrhea but does NOT relieve nasal congestion and has more side effects than placebo. 3, 1

Combination Products

• Antihistamine-decongestant-analgesic combinations provide significant relief in 1 out of 4 adults and may be considered for patients with multiple cold symptoms. 3

Treatments That Do NOT Work

The following should NOT be used for common cold nasal congestion:

• Intranasal corticosteroids have no benefit for symptomatic relief from the common cold (Level 1a evidence). 3, 8
• Antibiotics provide no benefit and cause significant adverse effects; they should never be prescribed for uncomplicated common cold. 3
• Second-generation antihistamines (loratadine, cetirizine) are ineffective for nasal congestion in non-allergic patients and may worsen congestion by drying nasal mucosa. 3
• Steam/heated humidified air shows no benefits for common cold symptoms. 3

Critical Safety Considerations

Topical Decongestant Warnings

• Rhinitis medicamentosa (rebound congestion) develops with topical decongestant use beyond 3-5 days, creating a cycle of worsening congestion that requires the medication to feel normal. 1, 3
• Patients must be explicitly counseled about the 3-5 day maximum duration before starting treatment. 1

Oral Decongestant Precautions

• Use with caution in first trimester pregnancy due to potential fetal heart rate changes. 1
• Monitor for cardiovascular effects and CNS stimulation, particularly in patients with hypertension or cardiac disease. 1

Pediatric Contraindication

• Over-the-counter cough and cold medications, including decongestants, should be avoided in children under 6 years due to lack of proven efficacy and potential toxicity. 1

Practical Treatment Algorithm

1. For immediate relief (next 1-2 hours): Use topical oxymetazoline 0.05% spray, 2-3 sprays per nostril every 10-12 hours, maximum 3-5 days. 1, 2

2. For sustained relief over several days: Use oral pseudoephedrine 60 mg every 4-6 hours for 3-5 days. 1, 9

3. Add paracetamol 500-1000 mg every 4-6 hours if nasal obstruction is particularly bothersome or if other cold symptoms (headache, malaise) are present. 3, 1

4. Consider nasal saline irrigation as a safe adjunct without time limitations. 3, 1

5. Reassure patients that symptoms typically last up to 2 weeks and to follow up only if symptoms worsen or exceed expected recovery time. 3