What is the best treatment approach for a patient experiencing nasal congestion and a runny nose, potentially due to allergies, and considering the patient may have a history of respiratory conditions such as asthma or COPD?

Treatment of Nasal Congestion and Runny Nose

Intranasal corticosteroids are the most effective first-line treatment for nasal congestion and runny nose, particularly when symptoms are due to allergies, and they are safe for patients with asthma or COPD. 1

Initial Treatment Algorithm

For Allergic Rhinitis (Primary Diagnosis)

First-Line Monotherapy:

• Intranasal corticosteroids (e.g., fluticasone propionate 50 mcg per spray) are the most effective single medication class for controlling all four major symptoms: sneezing, itching, rhinorrhea, and nasal congestion 1
• Use 1-2 sprays per nostril once daily (adults ≥12 years); 1 spray per nostril once daily (children 4-11 years) 2
• Direct sprays away from the nasal septum to minimize local irritation and bleeding 1
• Maximum effect may take several days, so continuous daily use is necessary during allergen exposure 1, 2

Second-Line Monotherapy (if intranasal steroids not tolerated or preferred):

• Oral second-generation antihistamines (cetirizine, loratadine, desloratadine, fexofenadine, levocetirizine) for sneezing, itching, and rhinorrhea—but these have minimal objective effect on nasal congestion 1
• Fexofenadine, loratadine, and desloratadine cause no sedation at recommended doses; cetirizine may cause sedation 1
• Intranasal antihistamines (azelastine) are equal or superior to oral antihistamines and have clinically significant effect on congestion, with rapid onset suitable for as-needed use 1

For Prominent Nasal Congestion

If congestion persists despite intranasal corticosteroids:

• Add intranasal oxymetazoline for severe congestion, but limit use to <3 days to avoid rhinitis medicamentosa (rebound congestion) 1, 3
• Oral pseudoephedrine 60 mg every 4-6 hours reduces nasal congestion effectively 1, 4, but use with extreme caution or avoid entirely in patients with hypertension, cardiovascular disease, hyperthyroidism, closed-angle glaucoma, or bladder neck obstruction 1, 3
• Oral phenylephrine is NOT recommended—it has poor oral bioavailability due to extensive first-pass metabolism and questionable efficacy 1, 3, 5

Combination therapy for inadequate response:

• Intranasal corticosteroid + intranasal antihistamine is the most effective additive combination 1
• Oral antihistamine + oral decongestant (e.g., desloratadine/pseudoephedrine) is effective when nasal sprays are not tolerated 1, 6
• Do NOT routinely combine intranasal corticosteroid + oral antihistamine—largest trials show no significant benefit 1
• Do NOT use leukotriene receptor antagonists (montelukast) as primary therapy; they are less effective than intranasal corticosteroids and oral antihistamines 1

For Prominent Rhinorrhea

• Intranasal ipratropium bromide effectively reduces rhinorrhea but has no effect on other nasal symptoms 1
• Can be combined with intranasal corticosteroids for additive effect without increased adverse events 1

Special Considerations for Respiratory Comorbidities

Patients with Asthma or COPD:

• Intranasal corticosteroids are safe and preferred—they do not cause clinically significant systemic effects at recommended doses 1
• Oral decongestants (pseudoephedrine) should be used with caution due to potential for tachyarrhythmias, insomnia, and hyperactivity, especially when combined with other stimulant medications 1
• Consider montelukast if patient has both allergic rhinitis and asthma, as it is approved for both conditions, though it should not be primary therapy for rhinitis alone 1
• Assess and document asthma control, as improved rhinitis management may improve asthma symptoms 1

Patients with Hypertension:

• Avoid oral pseudoephedrine—it causes measurable increases in systolic blood pressure and heart rate 3
• Intranasal oxymetazoline is preferred for severe congestion in hypertensive patients, as it provides rapid relief without significant systemic blood pressure elevation 3
• Intranasal corticosteroids, nasal saline, and antihistamines are safe alternatives with no cardiovascular effects 3

Adjunctive Therapies

• Nasal saline irrigation (buffered hypertonic 3-5% saline) improves quality of life, decreases symptoms, and decreases medication use, particularly in patients with frequent symptoms 1, 3
• Can be used alone or in conjunction with other treatments 1

Common Pitfalls to Avoid

• Do NOT use first-generation antihistamines (diphenhydramine, chlorpheniramine) as first-line—they cause sedation, performance impairment (often unperceived), and anticholinergic effects 1
• Do NOT use topical decongestants >3-5 consecutive days without a prolonged drug-free period due to risk of rhinitis medicamentosa 1
• Do NOT assume antihistamines alone will relieve congestion—they are ineffective for this symptom 1, 5
• Do NOT use antihistamines for non-allergic rhinitis in non-atopic patients—they have no role and may worsen congestion by drying nasal mucosa 1
• Do NOT use oral decongestants in children <6 years due to risk of agitated psychosis, ataxia, hallucinations, and death 1

When to Refer

Consider referral to allergist/immunologist if: 1

• Symptoms persist despite appropriate pharmacotherapy
• Complications develop (sinusitis, otitis media, nasal polyps)
• Systemic corticosteroids have been required
• Symptoms significantly impair quality of life or function
• Immunotherapy is being considered for inadequate response to pharmacotherapy 1