Can a patient with ocular hypertension who is using intranasal fluticasone safely take oral Sudafed (pseudo‑ephedrine) for nasal congestion?

Can a Patient with Ocular Hypertension Safely Use Oral Sudafed?

Yes, a patient with ocular hypertension who is using intranasal fluticasone can safely take oral pseudoephedrine (Sudafed) for short-term nasal congestion relief, as pseudoephedrine does not directly raise intraocular pressure and intranasal fluticasone does not cause clinically significant IOP elevation. 1, 2

Understanding the Safety Profile

Pseudoephedrine and Intraocular Pressure

• Oral decongestants like pseudoephedrine should be used with caution in patients with glaucoma due to theoretical concerns, but the primary mechanism of action (α-adrenergic vasoconstriction) does not directly increase intraocular pressure. 1
• The caution mentioned in rhinitis guidelines relates more to angle-closure glaucoma risk rather than open-angle glaucoma or ocular hypertension, where the drainage angle remains open. 1
• Pseudoephedrine's main cardiovascular effects are systemic vasoconstriction leading to modest blood pressure elevation (approximately 1 mmHg systolic), not direct effects on aqueous humor dynamics. 3, 4

Intranasal Fluticasone Safety

• Intranasal corticosteroids including fluticasone propionate cause variations in intraocular pressure that remain within normal limits and do not produce clinically significant IOP elevation. 2
• A prospective study of 360 patients using intranasal steroids (including fluticasone) for up to one year found only discreet elevations that stayed within normal parameters. 2
• Intranasal budesonide irrigations (a higher-dose topical steroid) given for periods of 1-22 months did not increase IOP above 21 mmHg in patients without pre-existing glaucoma. 5

Clinical Recommendations

Safe Use Parameters

• For short-term nasal congestion (3-7 days), oral pseudoephedrine can be used safely in patients with ocular hypertension, provided they do not have uncontrolled systemic hypertension or other cardiovascular contraindications. 1, 3
• The patient should continue their intranasal fluticasone as prescribed, since it provides effective nasal symptom control without affecting IOP. 2, 6
• Monitor for systemic side effects of pseudoephedrine including insomnia, irritability, and palpitations rather than ocular concerns. 1

Preferred Alternative Approach

• If the patient has concerns or wants the safest option, topical nasal decongestants (oxymetazoline/Afrin) for ≤3 days are preferable to oral pseudoephedrine, as they cause primarily local vasoconstriction with minimal systemic absorption. 3, 4
• Continuing intranasal fluticasone alone may provide adequate relief, as it effectively treats both nasal and ocular symptoms of allergic rhinitis without cardiovascular or IOP concerns. 6

Important Caveats and Contraindications

When to Avoid Pseudoephedrine

• Absolute contraindication: Patients taking monoamine oxidase inhibitors (MAOIs) should never use pseudoephedrine due to risk of hypertensive crisis. 3, 4
• Relative contraindications requiring extreme caution include uncontrolled systemic hypertension, arrhythmias, coronary artery disease, cerebrovascular disease, and hyperthyroidism. 1, 3, 4
• Never combine pseudoephedrine with other sympathomimetic agents (including stimulant medications like amphetamines) due to additive cardiovascular effects and risk of hypertensive crisis. 3, 7

Monitoring Considerations

• Patients with controlled systemic hypertension can use pseudoephedrine but should have blood pressure monitored due to interindividual variation in response. 4, 8
• The patient's ophthalmologist should continue routine IOP monitoring as part of ocular hypertension management, but pseudoephedrine use does not necessitate more frequent checks. 1
• If using pseudoephedrine for more than a few days, consider switching to intranasal corticosteroids as the primary therapy, which are more effective for sustained symptom control without systemic effects. 1, 3

Common Clinical Pitfalls to Avoid

• Do not confuse ocular hypertension (elevated IOP without optic nerve damage) with angle-closure glaucoma—the latter has different contraindications for sympathomimetic agents. 1
• Do not assume that topical nasal decongestants can be used long-term; rhinitis medicamentosa can develop as early as 3 days with regular use. 1
• Do not recommend phenylephrine as an oral alternative—it is extensively metabolized in the gut and has poor efficacy as an oral decongestant. 1, 3
• Do not overlook concomitant caffeine use, which produces additive adverse effects with pseudoephedrine including elevated blood pressure and palpitations. 4