Many people who suffer from nasal and sinus blockages regularly use oral and topical decongestants to help clear airways and manage the symptoms of allergies. Whilst the majority of people use decongestants sparingly, their prolonged use can present a number of healthcare problems as a result of overuse. Some of the concerns with long term use include rebound nasal congestion and a decrease in response from medication.
Rebound nasal congestion
Rebound nasal congestion is medically referred to as rhinitis medicamentosa. It is associated with the use of decongestants long after they are effective which commonly results in prolonged nasal congestion.
In more general pharmacological terms, the ‘rebound effect’ or ‘rebound phenomenon’ refers to the emergence or re-emergence of symptoms more severe than those that were initially treated.
It typically occurs after 3-5 days of decongestant use, resulting in damage to the nasal passage and an inability to respond to the decongestant.
Tachyphylaxis
Tachyphylaxis is a rapid decrease in the response to a drug after repeated exposure to it over a short period of time (1). A number of studies have shown that a majority of people quickly developed tachyphylaxis when using topical nasal or ophthalmic decongestants. As such, longer-term use is not recommended, with the majority of pharmaceutical agents losing their effectiveness after a few days of use.
Addressing the rebound effect of decongestants
The most effective method for stopping rhinitis medicamentosa is to stop the use of decongestants immediately. Whilst it has been suggested that nasal decongestants have an addictive property, and a ‘weaning’ approach may be necessary, there does not appear to be any evidence to suggest that its misuse is linked to a clinical definition of addiction – a compulsive physiological need for and use of habit-forming substance known to be harmful.
There is very little evidence on strategies to reduce the usage of nasal decongestants, with only a solitary study suggesting that an effective way to withdraw from nasal decongestant use is to only use it on one nostril at a time, and using a prescribed decongestant to alleviate discomfort at night in order to aid sleep (3).
As opposed to addiction or serious misuse, it is perhaps more plausible to suggest that overuse results in symptoms that can best be classified as medication tolerance, in which larger and larger doses of an abused substance are necessary to achieve the same effect as the initial dose (4). It is also important to stop over-use of decongestants so that an accurate assessment can take place, as the real cause of the inflammation may have been missed. Many physicians and pharmacists will often advise against the use of decongestants altogether given the severity of some of their side effects, and the longer term harms associated with their use.
Nasal corticosteroids
Alternative treatments for nasal blockages, such as nasal corticosteroids, can be prescribed instead of a nasal decongestant and are often longer lasting.
One dose of a prescribed nasal corticosteroid typically lasts for a full day and addresses an allergy at its source, as well as blocking any inflammation-causing histamine for up to 12 hours. Crucially, prescription nasal decongestants that contain steroids do not cause a rebound effect, so they can be used on a longer term basis (if necessary) for patients with more persistent congestion.
Nasal decongestants were formulated specifically for short term use
Nasal decongestants and other health conditions
Nasal decongestants are not recommended for use in patients with a wide range of conditions including:
- Heart disease (due to increasing workload and stress on the heart)
- Hypertension (decongestant may raise blood pressure)
- Thyroid disease (they interact with medicines and increase the chance of an adverse reaction)
- Men with enlarged prostates that cause problems with urination
- Diabetics
They are also contraindicated in pregnancy as they can reduce foetal blood supply due to vasoconstriction of the uterine arteries. For breastfeeding women, there are a number of studies that suggest a possible link between decongestant use and tachycardia in the baby (5), as well as reduced milk production (6).
Decongestants can interact negatively with a wide range of prescription monoamine oxidase inhibitors (MAOIs) that are used to treat depression, anxiety and occasionally Parkinson’s disease. As such, their use is discouraged in patients with these conditions, and it is recommended that they are only used sparingly, under strict prescription from a doctor, if absolutely necessary.
References
1. Graf P, Juto JE (1995) Sustained use of xylometazoline nasal spray shortens the decongestive response and induces rebound swelling Rhinology 33(1):14-7
2. Settipana RA (2011) Other causes of rhinitis: mixed rhinitis, rhinitis medicamentosa, hormonal rhinitis, rhinitis of the elderly, and gustatory rhinitis Immunol Aller Clin North Am 31(3):457-67
3. Ramey JT, Bailen E, Lockey RF (2006) Rhinitis medicamentosa J Invest All Clin Immunol 16(3):148-155
4. Graf P, Hallen H (1997) One-week use of oxymetazoline nasal spray in patients with rhinitis medicamentosa 1 year after treatment ORL J Otorhinolaryngol Relat Spec 59:39-44
5. Aljazaf K, Hale TW, Ilett KF et al (2003) Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk Br J Clin Pharmacol 56:18-24
6. Mitchell JL (1999) Use of cough and cold preparations during breastfeeding J Hum Lact 15:347-349
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