What medications can be used to treat a patient with a runny nose, likely due to a common cold or allergies?

Medications for Runny Nose

For a runny nose due to the common cold, use a first-generation antihistamine combined with a decongestant (such as dexbrompheniramine 6 mg + pseudoephedrine 120 mg twice daily), while for allergic rhinitis, start with an intranasal corticosteroid (fluticasone, mometasone, or budesonide) as first-line therapy. 1, 2

Determining the Cause: Cold vs. Allergies

The treatment approach differs fundamentally based on whether the runny nose stems from a viral upper respiratory infection or allergic rhinitis:

Common Cold (Viral Rhinitis)

• Duration typically ≤10 days with general symptoms like fever and malaise 3
• Clear rhinorrhea without prominent itching or eye symptoms 4
• First-generation antihistamine/decongestant combinations are most effective through their anticholinergic properties, not antihistamine effects 1, 5

Allergic Rhinitis

• Symptoms include nasal congestion (94%), rhinorrhea (90%), sneezing, and itching of eyes, nose, and throat 4
• Pale, edematous turbinates on exam (seasonal) or erythematous turbinates with serous secretions (perennial) 4
• Intranasal corticosteroids are superior to antihistamines for controlling the full spectrum of symptoms 1, 2

Treatment Algorithm for Common Cold

First-Line: Antihistamine/Decongestant Combination

Use older-generation (first-generation) antihistamines combined with decongestants as the most effective approach 1, 5:

• Dexbrompheniramine 6 mg + pseudoephedrine 120 mg (sustained-release) twice daily, OR 1
• Azatadine 1 mg + pseudoephedrine 120 mg (sustained-release) twice daily 1
• These work primarily through anticholinergic effects to reduce secretions, not through antihistamine mechanisms 1
• Improvement typically occurs within days to 2 weeks 1

Critical Pitfall: Newer Antihistamines Don't Work for Colds

Second-generation antihistamines (loratadine, fexofenadine, cetirizine) with or without pseudoephedrine are ineffective for acute cough and rhinorrhea in viral upper respiratory infections 1, 5. The anticholinergic properties of first-generation agents are essential for symptom relief in non-histamine-mediated rhinitis 1.

Alternative: Ipratropium Bromide Nasal Spray

For patients who cannot tolerate first-generation antihistamines (glaucoma, benign prostatic hypertrophy), use ipratropium bromide 0.06% nasal spray: 2 sprays per nostril three times daily 6. This provides anticholinergic effects without systemic side effects, though it only addresses rhinorrhea, not congestion 6.

Adjunctive Therapies

• NSAIDs (ibuprofen, naproxen) for headache, ear pain, and muscle aches 5
• Nasal saline irrigation may improve symptoms, particularly hypertonic (3%-5%) saline 1
• Avoid antibiotics entirely—they provide no benefit and cause harm 5

Treatment Algorithm for Allergic Rhinitis

First-Line: Intranasal Corticosteroids

For moderate to severe or persistent allergic rhinitis, intranasal corticosteroids are the most effective single therapy 1, 2:

• Fluticasone propionate 200 mcg once daily (2 sprays per nostril) 7
• Alternative: Mometasone, budesonide, or triamcinolone 1, 4
• Symptom improvement may begin within 12 hours, but maximum effect requires several days 7
• Superior to antihistamines for nasal congestion and at least as effective for other symptoms 1, 2, 3

Second-Line: Oral Antihistamines

For mild intermittent allergic rhinitis or when sneezing/itching predominate, use second-generation antihistamines 1, 2:

• Fexofenadine is the preferred choice—truly non-sedating even at higher doses, ideal for patients requiring alertness or at fall risk 2
• Loratadine or desloratadine as alternatives—non-sedating at recommended doses 2
• Cetirizine or levocetirizine—more sedating (13.7% vs 6.3% placebo) but may have faster onset 2
• Effective for rhinorrhea, sneezing, and itching but limited effect on nasal congestion 2, 3

Intranasal Antihistamines

Azelastine or olopatadine nasal spray may be offered for seasonal, perennial, or episodic allergic rhinitis 1. These can cause sedation at recommended doses 2.

Combination Therapy

For inadequate response to monotherapy, combine intranasal corticosteroid with oral or intranasal antihistamine 1. Combination therapy provides enhanced efficacy without increased adverse events 6.

What NOT to Use

Do not offer oral leukotriene receptor antagonists as primary therapy—they are less effective than intranasal corticosteroids or antihistamines 1.

Decongestants: Use With Extreme Caution

Topical decongestants (xylometazoline, oxymetazoline) should not be used more than 3-5 consecutive days due to rebound congestion and rhinitis medicamentosa 1, 5. Oral pseudoephedrine can be used short-term but is less effective than topical agents 1.

Special Populations

Elderly Patients

Avoid first-generation antihistamines entirely—they increase risk of falls, fractures, cognitive impairment, and delirium 2. Use fexofenadine as first choice due to non-sedating properties and lack of anticholinergic effects 2.

Patients with Glaucoma or Benign Prostatic Hypertrophy

Avoid first-generation antihistamines and use ipratropium bromide nasal spray instead 1, 6.

Renal Impairment

Cetirizine requires 50% dose reduction in moderate renal impairment and should be avoided in severe impairment 2. Loratadine requires caution but no specific dose reduction 2.

Common Pitfalls to Avoid

• Don't use guaifenesin—no evidence supports its effectiveness for nasal discharge 1
• Don't use nasal corticosteroids for the common cold—they provide no symptomatic relief 5
• Don't assume all second-generation antihistamines are equally non-sedating—fexofenadine is superior in this regard 2
• Don't use topical decongestants beyond 5 days—this causes rhinitis medicamentosa 1, 5
• Don't prescribe antibiotics for viral rhinitis—they cause harm without benefit 5