What can be prescribed for a patient with nasal congestion?

Treatment Options for Nasal Congestion

Prescribe intranasal corticosteroids as first-line therapy for nasal congestion, as they are the most effective monotherapy with onset of action within 12 hours and superior efficacy compared to all other medication classes. 1

First-Line Therapy: Intranasal Corticosteroids

• Intranasal corticosteroids are the gold standard for treating nasal congestion, demonstrating superiority over oral antihistamines, leukotriene antagonists, and their combinations for all nasal symptoms including congestion. 1

• These medications work through anti-inflammatory mechanisms rather than vasoconstriction, eliminating the risk of rebound congestion that occurs with topical decongestants. 2

• Onset of symptom relief typically occurs within 12 hours, with minimal side effects. 1

• Examples include fluticasone, budesonide, and mometasone, which can be prescribed for both allergic and non-allergic rhinitis. 3, 4

Second-Line Options When First-Line Fails

Intranasal Antihistamines

• Add intranasal antihistamines (azelastine 0.15% or olopatadine 0.6%) if intranasal corticosteroids alone are insufficient. 3, 1

• Intranasal antihistamines are equal or superior to oral antihistamines for nasal congestion and have rapid onset of action. 3

• Azelastine does not cause rebound congestion because it works through H1-receptor antagonism and anti-inflammatory mechanisms, not vasoconstriction. 2

• Dosing for azelastine 0.15%: 1-2 sprays per nostril twice daily for patients ≥12 years; 1 spray twice daily for ages 6-11 years. 3

• Common side effects include bitter taste (which varies between formulations), epistaxis, and mild somnolence (0.4%-3%, similar to placebo). 3

• The combination product azelastine/fluticasone (Dymista) provides enhanced efficacy for patients requiring both medications. 3

Oral Decongestants

• Prescribe pseudoephedrine 60 mg every 4-6 hours for rapid relief of severe congestion when topical therapy is contraindicated or insufficient. 1

• Pseudoephedrine is the only oral decongestant with proven efficacy; phenylephrine should be avoided due to extensive first-pass metabolism rendering it ineffective at standard doses. 1, 5

• Use extreme caution or avoid entirely in patients with arrhythmias, angina pectoris, coronary artery disease, cerebrovascular disease, uncontrolled hypertension, hyperthyroidism, bladder neck obstruction, or glaucoma. 3, 1

• Monitor blood pressure in hypertensive patients, though elevation is rarely noted in normotensive patients. 1

• Oral decongestants cause insomnia, irritability, and palpitations in some patients. 3

Topical Decongestants (Short-Term Only)

• Prescribe oxymetazoline 0.05% nasal spray strictly limited to 3 days maximum for rapid relief of severe acute congestion. 1, 6

• Topical decongestants provide superior efficacy with onset within minutes but carry significant risk of rhinitis medicamentosa (rebound congestion) if used beyond 3-5 days. 1, 7, 4

• Explicitly warn every patient about the 3-day maximum duration to prevent rebound congestion. 1, 7

• Recent evidence suggests oxymetazoline may be safe for up to 7 days at standard dosing (400 μg total daily dose), but the conservative 3-5 day recommendation remains standard practice. 7

• Use with caution in the first trimester of pregnancy due to reported fetal heart rate changes. 1

• Use with care in children under 1 year due to narrow therapeutic window and increased risk of cardiovascular and CNS side effects. 1

Additional Adjunctive Options

Nasal Saline Irrigation

• Recommend nasal saline irrigation for symptomatic relief with minimal risk of adverse effects, particularly useful for drug-induced nasal congestion. 3, 1

Intranasal Anticholinergics

• Consider ipratropium bromide nasal spray if rhinorrhea is prominent, though it has no effect on congestion itself. 3

• Combining ipratropium with intranasal corticosteroids is more effective than either alone for rhinorrhea without increased adverse events. 3

Leukotriene Receptor Antagonists

• Consider montelukast in patients with both rhinitis and asthma, as it has similar efficacy to oral antihistamines. 1

Oral Antihistamines

• Second-generation oral antihistamines (loratadine, fexofenadine, cetirizine) are less effective for nasal congestion than for other nasal symptoms. 3, 1

• Avoid first-generation antihistamines due to significant sedation, performance impairment, and dangerous anticholinergic effects. 3, 1

• Combination products with pseudoephedrine provide additional benefit specifically for congestion but carry the cardiovascular risks of the decongestant component. 1

Critical Pitfalls to Avoid

• Never confuse intranasal antihistamines (azelastine, olopatadine) with topical decongestants—they have fundamentally different mechanisms and safety profiles. 2

• Do not allow patients to purchase over-the-counter topical decongestants without explicit counseling about the 3-day maximum duration. 7, 8

• Do not prescribe phenylephrine orally—it lacks efficacy due to first-pass metabolism. 1, 5

• Intranasal corticosteroids and antihistamines do not cause rebound congestion and can be used long-term safely. 2

Treatment Algorithm

1. Start with intranasal corticosteroid (e.g., fluticasone, mometasone) for all patients with nasal congestion requiring ongoing treatment. 1

2. Add intranasal antihistamine (azelastine or olopatadine) if symptoms persist after 2-4 weeks of intranasal corticosteroid therapy. 3, 1

3. Consider oral pseudoephedrine for breakthrough congestion in patients without cardiovascular contraindications, or for combination therapy with antihistamines. 1

4. Reserve topical decongestants (oxymetazoline) for acute severe congestion with strict 3-day limit. 1, 7

5. Add nasal saline irrigation as adjunctive therapy at any stage. 3, 1