What is the recommended dosage and precautions for a patient with nasal congestion taking Sudafed (pseudoephedrine), considering potential pre-existing conditions such as hypertension, thyroid disease, or glaucoma?

Sudafed (Pseudoephedrine) Dosing and Precautions for Nasal Congestion

Avoid Sudafed entirely in patients with hypertension, heart disease, thyroid disease, or glaucoma, and instead prescribe intranasal corticosteroids as first-line therapy, which are more effective for nasal congestion without cardiovascular risks. 1, 2, 3

Recommended Dosing (When Appropriate)

Standard dosing for adults and children ≥12 years:

• 60 mg every 4-6 hours 4
• Maximum 240 mg per day (8 tablets of 30 mg formulation) 4

Children ages 6-11 years:

• 30 mg every 4-6 hours 4
• Maximum 120 mg per day (4 tablets) 4

Children under 6 years:

• Contraindicated—do not use 4

Critical Contraindications and Precautions

Absolute contraindications per FDA labeling:

• Current MAOI use or within 2 weeks of discontinuation 4
• Heart disease 4
• Uncontrolled or poorly controlled hypertension 4
• Thyroid disease (hyperthyroidism) 4
• Diabetes 4
• Enlarged prostate with urinary retention 4
• Narrow-angle glaucoma 4

Cardiovascular risks:

• Pseudoephedrine causes measurable increases in systolic blood pressure (approximately 1 mmHg average, with individual variation) and heart rate through α-adrenergic vasoconstriction 1, 2
• The American College of Cardiology recommends immediately discontinuing pseudoephedrine in patients presenting with acute hypertension, as this represents a reversible cause 1
• Use with extreme caution or avoid entirely in patients with arrhythmias, angina pectoris, coronary artery disease, or cerebrovascular disease 2

Age restrictions:

• The French Society of Otorhinolaryngology recommends against use in patients under age 15 due to unpredictable severe cardiovascular and neurological adverse events that may occur even at low doses 5

Superior Alternative: Intranasal Corticosteroids

For patients with any of the above conditions, prescribe intranasal corticosteroids instead:

• Most effective medication class for controlling nasal congestion 2, 3
• No cardiovascular effects or blood pressure elevation 1, 3
• Onset of action within 12 hours, full benefit in 2 weeks 2
• Superior efficacy compared to oral antihistamine-leukotriene combinations 2

Specific intranasal corticosteroid options:

• Fluticasone or triamcinolone for chronic/recurrent congestion 3
• Direct spray away from nasal septum to minimize irritation and bleeding 1

Short-Term Alternative: Topical Decongestants

For severe acute congestion when oral decongestants are contraindicated:

• Oxymetazoline 0.05% nasal spray provides rapid relief within minutes 2, 3
• Strict 3-day maximum use to prevent rhinitis medicamentosa (rebound congestion) 1, 2
• Safer cardiovascular profile than oral pseudoephedrine in hypertensive patients 3
• Use with caution in first trimester pregnancy due to reported fetal heart rate changes 2
• Use with care in children under 1 year due to narrow therapeutic window 2

Drug Interactions and Warnings

Critical interactions:

• Never combine with other sympathomimetic agents—risk of hypertensive crisis 1
• Avoid concomitant caffeine use—produces additive adverse effects including elevated blood pressure, insomnia, irritability, and palpitations 1

Monitoring requirements:

• Stop use if nervousness, dizziness, or sleeplessness occur 4
• Discontinue if symptoms do not improve within 7 days or occur with fever 4
• Recheck blood pressure 24-48 hours after discontinuation in hypertensive patients to confirm resolution 1

Combination Therapy Considerations

When pseudoephedrine is appropriate:

• Combination with antihistamines (e.g., desloratadine-pseudoephedrine) provides superior relief of all allergic rhinitis symptoms compared to monotherapy 6, 7
• Improvement in nasal congestion observed by day 2 of combination therapy 7

Pregnancy and Lactation

• Consult healthcare professional before use if pregnant or breastfeeding 4
• The American College of Allergy, Asthma, and Immunology recommends caution during first trimester due to reported fetal heart rate changes 2

Safe Adjunctive Therapy

Nasal saline irrigation:

• Completely safe with no cardiovascular effects 1, 3
• Beneficial for chronic rhinorrhea and drug-induced nasal congestion 2
• No drug interactions 3