What should I use for my nasal/sinus congestion? What are the differences between my options?

Question: What should I use for my nasal/ sinus congestion? What are the differences between my options?

Answer: Great question! Congestion is the general term for feeling stuffy due to inflammation and excess mucus and fluids lining the air passages of the nose. Congestion can occur from bacteria and/or viruses, allergens/ pollutants that can irritate the nasal passages and sometimes it can be experienced in pregnancy!

When deciding what to use it is important to consider the symptoms that you are experiencing. Since there are so many options available it would best to talk to your local pharmacist to help figure out which option is best fit for you!

Decongestants

Decongestants decrease the blood flow in the nasal mucosa and shrink the blood vessels that cause congestion in the nasal passages. Decongestants would be more appropriate if you are experiencing nasal or sinus congestion (feeling “stuffy”, headache, fever, etc.).

Pseudoephedrine (e.g. Sudafed®): Pseudoephedrine is a decongestant that is stimulating so it may cause individuals to be more energized, which would be best to avoid during the evening. Because pseudoephedrine can be used to manufacture methamphetamine, it’s now kept behind the pharmacy counter. You must provide identification to purchase it, and stores track how much you purchase. The maximum limit in Washington State and federally is a daily sale of 3.6 grams and no more than buying 9 grams during a 30-day period.

Dosage forms: tablets, caplets, oral solution

(Not recommended for use in children < 2 years, pregnant individuals, individuals with cardiovascular disease [e.g. hypertension, ischemic heart disease] and elderly patients)

Phenylephrine (e.g. Neo-Synephrine, Sudafed PE®): Phenylephrine is also a decongestant. Generally, a little safer than pseudoephedrine in the elderly population however it is less effective.

Dosage forms: tablets, caplets, capsules, oral solution

(Not recommended for children < 4 years and patients with severe hypertension or ventricular tachycardia. Use caution in elderly and pregnant patients)

Antihistamines

Antihistamines work by preventing the effects of a substance called histamine, which is produced by the body. Histamine produces allergy-like symptoms. If you are experiencing a runny nose, and itchy or watery eyes then an antihistamine would be preferred. Anti-histamines work by “drying” up the fluids, so it should be avoided in patients that already have a problem urinating. Also, they can increase the likelihood of falls occurring, so use cautiously in the elderly population with a greater fall risk.

2^nd and 3^rd generation (e.g. loratadine (Claritin®), certrizine (Zrytec®), fexofenadine (Allegra®) Second and third generation anti-histamines have less of a central effect and are more specific to the histamine receptors they would like to target, resulting in more using specific uses. Benadryl® (diphenhydramine) is considered a 1^st generation antihistamine, so it can be interchangeably however it is notorious for being drowsier and would not be an ideal choice to use for congestion.

Dosage forms: tablets, capsules,

(Not recommended for use in children < 12 years of age. Limit use in elderly population. May be considered in pregnancy since it is less sedating than first generation)

Question: Can I use an antihistamine in addition to a decongestant?

Answer: Yes, it may be used in addition to a decongestant, however it should be avoided in children. Antihistamines alone will not help alleviate nasal congestion significantly because it is preferred in patients with itchy or runny noses/ eyes typically experienced in allergies.

Unique products | Can’t use the options above? Pregnant, hypertension, elderly (+65 years) etc.

Oxymetazoline (e.g. Afrin®): Topical nasal decongestant spray that helps promote drainage and improve ventilation. Doesn’t carry a warning against use in patients with hypertension. However, it should not be used for more typically 3 days due rebound congestion. Rebound congestion is the worsening of the original congestion, this is due to the nasal passage’s dependence on the medication to keep the blood vessels constricted.

(Not recommended for use in children < 6 years of age).

Propylhexedrine (e.g. Benzedrex): Topical decongestant that is supplied as a nasal inhaler. A nasal inhaler is a nasal stick that gives off moisture and vapors with a cooling effect and decongestant effect to the nasal passages, making it easier to breathe through your nose. Doesn’t carry a warning against use in patients with hypertension. However, it should not be used for more typically 3 days due rebound congestion.

(Not recommended for use in children < 6 years of age).

Nasal strips (e.g. Breathe Right): Help open nasal passages so it is easier to breathe through your nose and close your mouth. Strips can be used for up to 12 hours. Can be used in both children and adults

(Not recommended for use in children < 5 years of age).

Nasal Saline Irrigation (e.g. Neti Pot): Saline helps relieve congestion by thinning out the mucus in the nasal cavities. To use this product, the individual needs to bend their head over to one side and pour the saline into one nostril. By bending the head to the side, it will help the saline flow from one nostril to the other. The aim is to have the solution to the back of the head and not the top of the head. In some populations such as pregnant patients it would be best to avoid any type of decongestant medication due to possible effects on the fetus. Some people rinse out their nose every day and some patients rinse it out every other day. For patients with chronic sinusitis (for over 3 months), it is recommended that they rinse their nose daily. (Can use in all ages)
Humidifiers: Increasing humidity may also be helping in providing relief through adding moisture in the air and loosening up the mucus secretions of the nasal passages. Cool mist is preferred to help ease the coughing and congestion. (Can use in all ages)

Prepared by Michelle Okocha PharmD Candidate 2020

Resources:

American Heart Association (AHA). Over-the-counter medications. AHA website. heart.org/HEARTORG/Conditions/HighBloodPressure/PreventionTreatmentofHighBloodPressure/Over-the-Counter-Medications_UCM_303245_Article.jsp#.V-v0GtArLwe. Accessed September 13, 2016.

Herring CT, Maryansky K, Trivette K, Hemberg N. Decongestant use in hypertension. US Pharm. 2006;7:80-88.

Moore, Clarence D. “Decongestants and Hypertension: Dangerous Together.” Pharmacy Times, 18 Nov. 2016, https://www.pharmacytimes.com/publications/issue/2016/november2016/decongestants-and-hypertension-dangerous-together.