Treatment of Persistent Runny Nose and Congestion Associated with Influenza
For persistent runny nose and congestion associated with the flu, use intranasal corticosteroids (fluticasone 2 sprays per nostril once daily) combined with saline nasal irrigation, along with oral analgesics (ibuprofen or acetaminophen) for symptomatic relief. 1, 2, 3
Symptomatic Treatment Algorithm
First-Line Therapy: Intranasal Corticosteroids
- Intranasal corticosteroids provide modest but clinically meaningful symptom relief for nasal congestion and rhinorrhea in viral upper respiratory infections. 1
- Start fluticasone propionate 200 mcg daily (2 sprays of 50 mcg per nostril once daily) for adults and adolescents ≥12 years. 4
- For children 4-11 years, use 100 mcg daily (1 spray per nostril once daily). 4
- Maximum benefit typically occurs after several days of regular use, though some improvement may be seen within 12 hours. 4
- The number needed to treat is 14 for symptom improvement, with only minor adverse events (epistaxis, headache, nasal itching). 1
Adjunctive Therapy: Saline Nasal Irrigation
- Saline nasal irrigation significantly improves nasal congestion and runny nose symptoms in upper respiratory infections. 5
- Use isotonic or sea salt-derived physiological saline nasal spray 2-3 times daily. 1, 5
- Saline irrigation works by thinning mucus, clearing inflammatory proteins, and flushing irritants from nasal passages. 1
- The effective rate for symptom reduction is 87.3% for nasal congestion and 85.9% for runny nose when added to supportive care. 5
Systemic Symptomatic Relief
- Use ibuprofen or acetaminophen for fever, myalgias, and headache associated with influenza. 2, 3
- Ibuprofen is specifically recommended by the British Thoracic Society for flu symptoms. 3
- Use the lowest effective dose for the shortest duration necessary. 3
- Never use aspirin in children <16 years due to Reye's syndrome risk. 2, 3
What NOT to Use
Avoid Topical Decongestants for Prolonged Use
- While topical decongestants (oxymetazoline, xylometazoline) provide rapid relief, limit use to 3 days maximum to avoid rhinitis medicamentosa. 6
- Short-term use (≤3 days) can help open nasal passages to allow better penetration of intranasal corticosteroids. 6
- Despite one study showing no rebound with 4 weeks of use 7, clinical guidelines consistently recommend limiting duration to prevent medication-induced rhinitis. 1, 6
Ineffective Therapies
- Oral antihistamines are NOT effective for non-allergic rhinitis or viral upper respiratory infections. 1
- Antihistamines should only be used if there is a clear allergic component. 1
- Systemic corticosteroids are not indicated for uncomplicated influenza symptoms. 1
Antiviral Considerations
When to Consider Oseltamivir
- Oseltamivir is NOT indicated for isolated nasal symptoms in otherwise healthy patients with influenza. 2, 8
- Oseltamivir should only be initiated if ALL three criteria are met: acute influenza-like illness, fever >38°C, and symptomatic for ≤48 hours. 2
- For patients with persistent nasal symptoms but no fever or systemic illness, supportive care alone is appropriate. 2, 8
Supportive Care Measures
- Ensure adequate hydration (oral fluids). 2
- Rest and avoid irritants (smoking, strong odors). 3
- Monitor for red flag symptoms requiring re-evaluation: shortness of breath at rest, bloody sputum, recrudescent fever after initial improvement, altered mental status, or inability to maintain oral intake. 2
Common Pitfalls to Avoid
- Do not prescribe antibiotics for uncomplicated influenza with nasal symptoms alone - they are ineffective and promote resistance. 1, 2
- Do not use prolonged topical decongestants beyond 3 days, as this can worsen congestion. 1, 6
- Do not delay intranasal corticosteroids - they require several days for maximum effect, so early initiation is important. 1, 4
- Do not assume all nasal symptoms require antiviral therapy - oseltamivir has specific indications and is not needed for isolated nasal congestion/rhinorrhea. 2, 8