What are the recommended medications and treatments for a blocked nose?

Medications for Nasal Congestion

For acute nasal congestion, start with intranasal corticosteroids (such as fluticasone or mometasone) as first-line therapy, combined with nasal saline irrigation; reserve topical decongestants for severe congestion only, limiting use to 3-5 days maximum to prevent rebound congestion. 1, 2

First-Line Treatment: Intranasal Corticosteroids

Intranasal corticosteroids are the most effective medication class for treating nasal congestion, superior to all other options including oral antihistamines and decongestants. 2

Specific Agent Selection and Dosing

• Fluticasone propionate: 2 sprays per nostril once daily (200 mcg total) for adults and children ≥12 years; 1 spray per nostril daily for children 4-11 years 2, 3
• Mometasone furoate: 2 sprays per nostril once daily (200 mcg total) for adults and children ≥12 years; 1 spray per nostril daily for children 2-11 years 2
• Triamcinolone acetonide: Available over-the-counter; 1 spray per nostril daily for children ≥2 years 2

Expected Timeline and Patient Counseling

• Symptom relief begins within 12 hours, with some patients experiencing benefit as early as 3-4 hours 2
• Maximal efficacy requires days to weeks of regular daily use—patients must understand this is maintenance therapy, not immediate rescue treatment 2
• Continue treatment for minimum 2 weeks before assessing full therapeutic benefit 2

Administration Technique to Minimize Side Effects

• Direct spray away from nasal septum using contralateral hand technique (right hand for left nostril, left hand for right nostril)—this reduces epistaxis risk by four times 2, 4
• Keep head upright during administration 2
• If using saline irrigation, perform it before applying steroid spray 2

Adjunctive Treatment: Nasal Saline Irrigation

Saline irrigation provides mechanical clearance of mucus and improves mucociliary function, offering additional symptomatic benefit when combined with intranasal steroids. 1, 5

Evidence for Efficacy

• Multiple studies show saline irrigation improves symptoms when used as sole treatment or as adjunct to other therapies 1, 5
• One large pediatric trial demonstrated significant reduction in nasal secretion score (MD -0.31,95% CI -0.48 to -0.14) and nasal obstruction score (MD -0.33,95% CI -0.47 to -0.19) 6
• Saline irrigation reduces need for decongestant medications 6

Practical Recommendations

• Use isotonic or hypertonic saline solutions; hypertonic may provide greater benefit for objective measures 1, 5
• Volume retained after irrigation is minimal (2.5% or approximately 6 mL from 240 mL irrigation), limiting systemic drug exposure concerns 7
• Well tolerated with only minor side effects (nasal irritation) that are outweighed by benefits 5

Topical Decongestants: Short-Term Use Only

Topical decongestants (oxymetazoline, xylometazoline) provide rapid relief but must be strictly limited to prevent rhinitis medicamentosa. 1, 4

When to Consider Adding Decongestants

• Severe nasal congestion preventing adequate penetration of intranasal steroids 1, 4
• Temporary use (≤3-5 days) as bridge therapy while starting intranasal corticosteroids 1, 2, 8

Preventing Rebound Congestion

• When oxymetazoline is combined with intranasal corticosteroids from the outset, rebound congestion can be prevented entirely 4
• Studies show 2-4 weeks of combined oxymetazoline plus intranasal steroid (mometasone) was more effective than steroid alone without causing rebound swelling 1, 4
• Apply oxymetazoline first, wait 5 minutes, then apply intranasal steroid 4

Critical Warning

• Never use topical decongestants alone for more than 3 days—always combine with intranasal corticosteroid if extending beyond this timeframe 1, 2, 8, 4
• Prolonged solo use causes rhinitis medicamentosa (rebound congestion) 1, 2, 8

Oral Decongestants

Oral decongestants (pseudoephedrine) may provide symptomatic relief but have significant limitations. 1, 8

Important Contraindications and Cautions

• Use with extreme caution in patients with hypertension, cardiac arrhythmia, angina, cerebrovascular disease, bladder neck obstruction, glaucoma, or hyperthyroidism 1, 8
• Less effective than intranasal corticosteroids for nasal congestion 2
• Consider only as adjunctive therapy, not first-line treatment 1

What NOT to Use

Antihistamines

• Oral antihistamines are relatively ineffective for nasal congestion and significantly less effective than intranasal corticosteroids for all nasal symptoms 2, 8
• Newer non-sedating antihistamines show minimal benefit for common cold/viral rhinitis symptoms 8
• May be considered only for associated sneezing and itching, not for congestion 1

Antibiotics

• Never prescribe antibiotics for viral rhinitis or uncomplicated nasal congestion—they are completely ineffective and contribute to antimicrobial resistance 1, 8
• Consider antibiotics only if bacterial sinusitis is confirmed (symptoms >10 days without improvement or "double worsening") 8

Systemic Corticosteroids

• Not indicated for routine nasal congestion 1
• Reserve for very severe or intractable symptoms as short 5-7 day course only 2, 8
• Parenteral (injectable) corticosteroids are contraindicated due to risk of prolonged adrenal suppression 2, 8

Treatment Algorithm for Nasal Congestion

Acute Viral Rhinitis (Common Cold)

1. Start nasal saline irrigation for mechanical clearance 8
2. Add intranasal corticosteroid for modest symptom relief 1, 8
3. Consider short-term topical decongestant (≤3-5 days) if congestion is severe 8
4. Analgesics (acetaminophen, ibuprofen) for associated pain/fever 1, 8

Allergic Rhinitis

1. Intranasal corticosteroid as first-line monotherapy 2
2. Add nasal saline irrigation as adjunct 2, 5
3. If inadequate response after 2 weeks, consider adding intranasal antihistamine (azelastine) 2
4. For severe initial congestion, may add topical decongestant for 3-5 days while starting steroid 2, 4

Chronic Rhinosinusitis

1. Intranasal corticosteroid as primary treatment (minimum 8-12 weeks) 1
2. Nasal saline irrigation as essential adjunct 1, 5
3. For very blocked nose, temporary addition of topical decongestant (combined with steroid to prevent rebound) may be considered 1, 4
4. Oral antibiotics only if bacterial infection confirmed 1

Common Pitfalls to Avoid

• Prescribing antibiotics based on colored nasal discharge alone—color reflects neutrophils, not bacterial infection 8
• Using topical decongestants beyond 3-5 days without concurrent intranasal steroid—guarantees rebound congestion 1, 2, 8, 4
• Discontinuing intranasal steroids when symptoms improve—these are maintenance medications requiring continuous use 2
• Starting with oral antihistamines or leukotriene antagonists instead of intranasal steroids—these are significantly less effective 2
• Expecting immediate relief from intranasal steroids—counsel patients that full benefit takes days to weeks 2

Safety Considerations for Long-Term Intranasal Steroid Use

• No hypothalamic-pituitary-adrenal axis suppression at recommended doses 2
• No effect on growth in children at recommended doses 2
• No increased risk of cataracts or glaucoma 2
• Most common side effect is mild epistaxis (blood-tinged secretions) in 5-10% of patients 2
• Nasal septal perforation is rare but possible—periodically examine septum during long-term use 2