What are the best nasal decongestant and cough medicine options for a patient with nasal congestion and cough?

Best Nasal Decongestant and Cough Medicine

For nasal congestion, use pseudoephedrine 60 mg every 4-6 hours (not phenylephrine, which is ineffective orally), and for cough, use dextromethorphan or codeine for short-term symptomatic relief in chronic bronchitis, though these are not effective for cough due to the common cold. 1, 2

Nasal Decongestant Recommendations

Oral Decongestants: Pseudoephedrine vs Phenylephrine

• Pseudoephedrine is the only effective oral decongestant and should be your first choice for nasal congestion in both allergic and nonallergic rhinitis 1, 2
• Phenylephrine is extensively metabolized in the gut, significantly reducing its bioavailability when administered orally, making it ineffective 1
• The efficacy of phenylephrine as an oral decongestant has not been well established in clinical studies 1

Dosing for pseudoephedrine: 60 mg every 4-6 hours for short-term relief (3-5 days maximum recommended) 3, 4

Topical Nasal Decongestants (Short-Term Only)

• Topical decongestants (oxymetazoline, xylometazoline, phenylephrine) are more effective than oral options but MUST be limited to 3 days maximum to prevent rhinitis medicamentosa (rebound congestion) 2, 1, 3
• Rebound congestion can develop as early as day 3-4 of continuous use, creating a cycle of worsening congestion and dependency 1
• Topical decongestants are appropriate for acute bacterial or viral infections, exacerbations of allergic rhinitis, and eustachian tube dysfunction 2

Safety Considerations for Decongestants

Screen for contraindications before prescribing:

• Use with caution in patients with cardiovascular disease, uncontrolled hypertension, hyperthyroidism, closed-angle glaucoma, and bladder neck obstruction 1, 3
• Pseudoephedrine increases systolic blood pressure by approximately 1 mmHg and heart rate by 2-3 beats per minute on average 3
• Monitor blood pressure in hypertensive patients, though elevation is rarely noted in normotensive patients and only occasionally in those with controlled hypertension 2, 1
• Do not use in children under 6 years due to risks of serious adverse effects including agitated psychosis, ataxia, hallucinations, and death 1

When Decongestants Are NOT the Answer

• For longer-term management (>5-7 days), switch to intranasal corticosteroids (e.g., fluticasone), which are the most effective medication class for controlling all four major symptoms of allergic rhinitis, especially nasal congestion 2, 1
• Intranasal corticosteroids do not cause rebound congestion and are safer for extended use 2
• Antihistamines have little objective effect on nasal congestion and should not be used as primary therapy for this symptom 2

Cough Medicine Recommendations

Central Cough Suppressants (Codeine and Dextromethorphan)

The evidence for cough suppressants is highly context-dependent:

• For chronic bronchitis: Central cough suppressants (codeine and dextromethorphan) are recommended for short-term symptomatic relief 2, 5
• For cough due to upper respiratory infection (common cold): Central cough suppressants have limited efficacy and are NOT recommended 2
• Codeine reduced cough counts by 40-60% in chronic bronchitis patients but showed no difference in cough frequency or severity in URI patients 2

Peripheral Cough Suppressants

• Peripheral cough suppressants (levodropropizine, moguisteine) are recommended for short-term relief in chronic or acute bronchitis but have limited efficacy for URI-related cough 2

First-Generation Antihistamine/Decongestant Combinations

For acute cough from the common cold specifically:

• First-generation antihistamine/decongestant combinations are strongly recommended for patients with acute cough from the common cold 2
• Over-the-counter combination cold medications are NOT recommended except for those containing older antihistamine/decongestant ingredients, until proven effective in randomized controlled trials 2
• Newer-generation, nonsedating antihistamines should NOT be used as they are ineffective for cough 2

Alternative Cough Treatments

• Ipratropium bromide (inhaled anticholinergic) is recommended for cough suppression in URI or chronic bronchitis 2
• Albuterol is NOT recommended for acute or chronic cough not due to asthma 2
• Zinc preparations are NOT recommended for acute cough due to the common cold 2

Clinical Algorithm for Combined Nasal Congestion and Cough

Days 1-3 (Acute Phase):

• Pseudoephedrine 60 mg every 4-6 hours for nasal congestion 3, 4
• Can add topical oxymetazoline for faster relief, but discontinue after day 3 1
• For cough: First-generation antihistamine/decongestant combination if due to common cold 2

Days 4-7:

• Continue pseudoephedrine if needed, but consider stopping after 5 days 3
• Stop topical decongestants completely to avoid rebound congestion 1
• If cough persists and is due to chronic bronchitis, consider dextromethorphan or codeine 2

Beyond 7 days:

• Switch to intranasal corticosteroids for ongoing nasal congestion 2, 1
• Investigate other causes of cough (post-nasal drip, GERD, asthma) as acute viral causes should have resolved 2

Common Pitfalls to Avoid

• Never prescribe oral phenylephrine - it is ineffective due to poor bioavailability 1
• Never extend topical decongestant use beyond 3 days - this leads to rhinitis medicamentosa requiring weeks to resolve 1
• Do not use cough suppressants for common cold-related cough - they are ineffective in this context 2
• Do not use newer-generation antihistamines for cough - only first-generation antihistamines combined with decongestants work 2
• Avoid decongestants entirely in children under 6 years due to serious safety concerns 1