Nasal Spray Recommendations for Runny Nose
For a runny nose due to allergies, use an intranasal corticosteroid (such as fluticasone propionate or mometasone furoate) as first-line therapy; for a runny nose due to the common cold, use ipratropium bromide 0.06% nasal spray. 1, 2
Allergic Rhinitis (Most Common Cause)
First-Line Treatment: Intranasal Corticosteroids
Intranasal corticosteroids are the most effective first-line treatment for allergic rhinitis and should be used as monotherapy initially. 1, 3 These medications work directly in the nose to block allergic reactions at the source by acting on multiple inflammatory substances including histamine, prostaglandins, cytokines, and leukotrienes. 2
Specific options include:
Fluticasone propionate (Flonase): For adults and children ≥12 years, use 2 sprays per nostril once daily (200 mcg total); for children 4-11 years, use 1 spray per nostril once daily. 3, 2
Mometasone furoate (Nasonex): For adults and children ≥12 years, use 2 sprays per nostril once daily (200 mcg total); for children 2-11 years, use 1 spray per nostril once daily. 3, 4
Triamcinolone acetonide (Nasacort): For children as young as 2 years, use 1 spray per nostril daily. 3
Important timing considerations: It may take several days for intranasal corticosteroids to reach maximum effect, so patients must continue regular daily use rather than as-needed dosing. 3, 2 Full benefit may not be evident for at least 2 weeks after initiation. 3
Second-Line Options When Intranasal Steroids Fail
If intranasal corticosteroids alone provide inadequate symptom control, add an intranasal antihistamine (azelastine) for combination therapy. 1, 3 The combination of fluticasone propionate and azelastine shows greater than 40% relative improvement compared to either agent alone. 3
Oral second-generation antihistamines (such as loratadine or cetirizine) can be used for patients with primary complaints of sneezing and itching, but they are less effective than intranasal corticosteroids for nasal congestion. 1
Do not use oral leukotriene receptor antagonists as primary therapy - they are significantly less effective than intranasal corticosteroids and should not be offered as first-line treatment. 1, 3
Common Cold (Viral Upper Respiratory Infection)
Specific Treatment for Rhinorrhea
Ipratropium bromide 0.06% nasal spray is the only medication specifically approved and effective for treating rhinorrhea caused by the common cold. 1, 5
Dosing:
- Adults and children ≥5 years: 2 sprays (84 mcg) per nostril 3 times daily for up to 4 days. 1
- Children 2-5 years: 2 sprays (84 mcg) per nostril 3 times daily for up to 4 days. 5
Mechanism: Ipratropium bromide is a quaternary anticholinergic agent that works locally on nasal mucosa to reduce rhinorrhea without systemic anticholinergic effects. 1 It does not alter physiologic nasal functions such as sense of smell or mucociliary clearance. 1
Adjunctive Measures for Common Cold
Saline nasal irrigation may provide modest symptomatic relief and can be used alone or in conjunction with other treatments. 1 Buffered hypertonic (3%-5%) saline irrigation showed modest benefit in clinical trials, though one randomized trial found no difference between hypertonic saline, normal saline, or observation. 1
Topical decongestants (xylometazoline or oxymetazoline) can provide rapid relief of nasal congestion but should be limited to 3-5 consecutive days maximum to avoid rebound congestion and rhinitis medicamentosa. 1, 6, 7 These are not appropriate for treating runny nose specifically, only congestion. 1
Antihistamines have no role in symptomatic relief of common cold rhinorrhea in non-allergic patients and may worsen congestion by drying nasal mucosa. 1
Critical Pitfalls to Avoid
Do not use topical decongestants for more than 3-5 days - prolonged use causes rebound congestion (rhinitis medicamentosa) and can lead to severe dependence requiring months to resolve. 1, 8, 7
Do not use antibiotics for viral upper respiratory infections - they are ineffective for the common cold and contribute to antimicrobial resistance. 1
Do not confuse treatment approaches - intranasal corticosteroids are for allergic rhinitis, not for treating common cold symptoms. 2 Ipratropium bromide is specifically for rhinorrhea from colds, not for allergic rhinitis as primary therapy. 1
Ensure proper administration technique for intranasal corticosteroids: prime the bottle before first use, shake before spraying, blow nose prior to use, keep head upright, use contralateral hand technique (spray right nostril with left hand), and direct spray away from nasal septum to minimize epistaxis risk. 3