What is the best approach to manage a patient with a history of gastrointestinal disorders, currently being treated with a proton pump inhibitor (PPI) such as omeprazole, who is now experiencing sinus congestion?

Managing Sinus Congestion in a Patient on PPI Therapy

Continue the omeprazole for the gastrointestinal disorder without interruption, and treat the sinus congestion with intranasal corticosteroids as first-line therapy, as these are the most potent pharmacologic treatment for nasal congestion and have no clinically significant interaction with PPIs. 1

Optimal Treatment for Sinus Congestion

First-Line Therapy

• Intranasal corticosteroids are the most effective long-term pharmacologic treatment for nasal congestion due to their broad anti-inflammatory activities and superior efficacy compared to other agents 1
• These agents work directly on mucosal inflammation, which is the principal cause of congestion in upper respiratory diseases 1
• No drug interaction concerns exist between intranasal corticosteroids and omeprazole, making this combination safe

Alternative or Adjunctive Options

• Oral decongestants (pseudoephedrine/phenylephrine) show efficacy for congestion and can be used short-term, with no interaction with PPIs 1
• Intranasal antihistamines improve congestion better than oral antihistamines if allergic rhinitis is suspected 1
• Topical decongestants provide rapid relief but should be limited to 3-5 days due to risk of rebound congestion (rhinitis medicamentosa) 1
• Oral H1-antihistamines and leukotriene receptor antagonists have only modest decongestant action 1

PPI Management Considerations

Continue Current Therapy

• Emphasize to the patient that PPIs are safe for continued use during treatment of sinus congestion 2
• The 2022 AGA guidelines specifically recommend clinicians emphasize PPI safety to address patient concerns that may affect compliance 2

Ensure Optimal PPI Dosing

• Confirm the patient takes omeprazole 30 minutes before meals (typically before breakfast), as improper timing dramatically reduces efficacy 3
• If the patient has been on PPI therapy for approaching 12 months without objective GERD diagnosis, consider scheduling endoscopy with prolonged wireless pH monitoring to establish appropriateness of long-term therapy 2

Critical Pitfalls to Avoid

• Do not discontinue or reduce PPI therapy to treat sinus congestion, as there is no therapeutic benefit and may worsen gastrointestinal symptoms
• Avoid prolonged use of topical nasal decongestants beyond 3-5 days to prevent rebound congestion 1
• Do not assume sinus congestion is related to GERD without proper evaluation; while laryngopharyngeal reflux can cause upper respiratory symptoms, isolated sinus congestion is more likely rhinosinusitis or allergic rhinitis 2

When to Consider GERD-Related Causes

• If the patient has isolated extra-esophageal symptoms (chronic cough, hoarseness, throat clearing) in addition to sinus congestion, perform upfront objective reflux testing off medication rather than empiric PPI escalation 2
• One study showed omeprazole 20 mg daily for 8 weeks reduced comorbid chronic rhinosinusitis symptoms in patients with confirmed laryngopharyngeal reflux 4
• However, this applies only when LPR is objectively confirmed, not for isolated sinus congestion 2