What are the appropriate medications for treating nasal congestion in adults and children, including considerations for hypertension, coronary artery disease, glaucoma, diabetes, hyperthyroidism, monoamine‑oxidase inhibitor use, and pregnancy?

Medications for Nasal Congestion

For nasal congestion, use oral or topical decongestants as first-line therapy, with topical agents (oxymetazoline) strictly limited to 3 days maximum to prevent rebound congestion, while oral pseudoephedrine can be continued longer if needed—but avoid decongestants entirely in patients with uncontrolled hypertension, coronary artery disease, or hyperthyroidism, using intranasal corticosteroids instead. 1

First-Line Treatment Algorithm

For Acute Nasal Congestion (Short-Term Relief)

Topical nasal decongestants provide the most rapid and effective relief:

• Oxymetazoline 0.05% nasal spray is the preferred topical agent, providing relief within minutes through direct nasal vasoconstriction 1, 2
• Adults and children ≥6 years: 2-3 sprays per nostril every 10-12 hours, maximum 2 doses per 24 hours 3
• Critical limitation: Never exceed 3 days of continuous use to prevent rhinitis medicamentosa (rebound congestion), which can develop as early as day 3-4 1, 4
• Children under 6 years: Use with extreme caution due to narrow therapeutic window and risk of cardiovascular/CNS side effects 1, 4

Oral decongestants as an alternative or adjunct:

• Pseudoephedrine 60 mg every 4-6 hours is the only oral decongestant with proven efficacy 1, 5
• Multiple doses show small but significant benefit for nasal congestion (standardized mean difference 0.49) 6, 7
• Can be used for longer duration than topical agents without causing rebound congestion 4
• Avoid phenylephrine: Extensive first-pass metabolism renders it ineffective at standard oral doses 1, 4

For Chronic or Recurrent Nasal Congestion

Intranasal corticosteroids are the most effective long-term option:

• First-line therapy for allergic rhinitis with congestion, superior to all other medication classes 1
• Onset of action within 12 hours, providing sustained efficacy without rebound congestion risk 1
• Examples: fluticasone, mometasone, budesonide 1
• Administration technique: Direct spray away from nasal septum to prevent epistaxis and septal perforation 1

Combination Therapy

Antihistamine-decongestant combinations provide comprehensive symptom relief:

• Desloratadine/pseudoephedrine or similar combinations show enhanced efficacy for nasal congestion compared to either component alone 6, 8, 9
• Benefit observed by day 2 of treatment 9
• Avoid first-generation antihistamine combinations due to significant sedation and dangerous anticholinergic effects 1
• No evidence of effectiveness in young children 6

Critical Contraindications and Special Populations

Cardiovascular Disease and Hypertension

Decongestants must be avoided or used with extreme caution in these patients:

• Pseudoephedrine causes measurable increases in systolic blood pressure (0.99 mmHg in normotensive patients, potentially more in hypertensive patients) and heart rate 1, 4, 2, 10
• Absolute or relative contraindications: Uncontrolled hypertension, arrhythmias, angina pectoris, coronary artery disease, cerebrovascular disease 1, 4, 2
• Preferred alternatives: Intranasal corticosteroids (no cardiovascular effects), nasal saline irrigation, or short-term topical oxymetazoline (minimal systemic absorption) 1, 2

Other High-Risk Conditions

Use extreme caution or avoid decongestants entirely in:

• Hyperthyroidism 1, 4
• Closed-angle glaucoma 4
• Bladder neck obstruction 4
• Diabetes (monitor closely) 1
• Concurrent MAOI use (absolute contraindication) 4

Pregnancy

• First trimester: Use caution with decongestants due to reported fetal heart rate changes 1, 4
• Topical agents preferred over oral if decongestant needed (less systemic absorption) 1

Pediatric Considerations

• Children under 6 years: Avoid oral and topical decongestants due to risk of agitated psychosis, ataxia, hallucinations, and death 1, 4
• Children 6-12 years: Use only with adult supervision at reduced doses 3
• Intranasal corticosteroids should be prescribed at lowest effective dose 1

Adjunctive and Alternative Therapies

Nasal saline irrigation:

• Provides symptomatic relief with minimal risk, particularly useful in children 6, 1
• Buffered hypertonic (3-5%) saline may have superior anti-inflammatory effect 6
• Safe option for patients with cardiovascular contraindications 2

Ipratropium bromide (intranasal anticholinergic):

• Effective for rhinorrhea but does not improve nasal congestion 6, 1
• Can be combined with intranasal corticosteroids for enhanced rhinorrhea control 1

Analgesics for associated pain:

• Acetaminophen may help relieve nasal obstruction and rhinorrhea 6
• NSAIDs provide benefit for headache and ear pain but do not significantly improve nasal congestion 6

Antihistamines alone:

• Limited short-term benefit (days 1-2 only) for overall symptoms in adults 6
• No clinically significant effect on nasal obstruction 6
• Only useful for congestion when combined with decongestants or in allergic patients 6, 1

Management of Rhinitis Medicamentosa (Rebound Congestion)

If rebound congestion develops from prolonged topical decongestant use:

• Immediately discontinue the topical decongestant 1
• Switch to intranasal corticosteroids for ongoing management 1
• For severe cases: Consider short course (5-7 days) of oral corticosteroids to accelerate mucosal recovery 1

Common Pitfalls to Avoid

• Never extend topical decongestant use beyond 3 days, even if symptoms persist—this creates a cycle of worsening congestion requiring weeks to resolve 1, 4
• Do not assume phenylephrine is effective or safer than pseudoephedrine—it has poor bioavailability and questionable efficacy 1, 4
• Do not use antihistamines alone for nasal congestion in non-allergic patients—they may worsen congestion by drying nasal mucosa 6
• Always educate patients on proper intranasal corticosteroid technique (aim away from septum) 1
• Monitor blood pressure in hypertensive patients taking oral decongestants 1, 4, 10