Rebound sinus congestion and addiction from sinus decongestant nasal sprays
Allergy, Asthma, Ear, Nose and Throat
October 20, 2015
| Author: The Super Pharmacist
Many individuals who suffer from nasal and sinus blockages regularly use oral and topical decongestants to help clear their airways and manage the symptoms of any underlying allergies. Whilst the large majority of people use decongestants sparingly, their prolonged use can present a number of healthcare problems as a result of overuse.
What are the problems associated with their long term use?
There are a number of issues associated with the long term use of decongestants. A number of studies have shown that a large majority of individuals quickly developed tachyphylaxis (a rapid decrease in the response to a drug after repeated exposure to it over a short period of time
) when using topical nasal or ophthalmic decongestants (1). As such, longer-term use is not recommended, with the majority of pharmaceutical agents losing their effectiveness after a few days. There are also some more severe side effects, with prolonged decongestant use resulting in ‘rebound nasal congestion’. This condition, associated with decongestant use long after they cease to be effective, commonly results in prolonged nasal congestion. This condition is known medically as rhinitis medicamentosa. In more general pharmacological terms, the ‘rebound effect’ or ‘rebound phenomenon’ refers to the emergence or re-emergence of symptoms in an individual of more severity than those that were initially treated. This is a particular problem for nasal congestion, and rebound medicamentosa is widely considered to be heavily underreported and undiagnosed (2). 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.
How can the rebound effect of decongestants be addressed?
The most effective method for stopping rhinitis medicamentosa is to stop the use of decongestants immediately. Whilst some individuals have suggested that nasal decongestants have an addictive property, and that 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. A study carried out in 2008 by a group of American physicians noted that the therapeutic effect of diode laser inferior turbinate reduction can provide a long-lasting recovery when compared with nasal decongestants, and also prevents addiction to such medicine, yet this is based on an unsubstantiated claim that addiction to decongestants is possible, or even a reality. There is no formal literature to support any such assertion, suggesting that there is either a significant evidence gap (and it may well be true) or it is deemed not worthy of investigation due to the suggestion of addiction with such substances having no firm physiological basis. There is also 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 of the patient’s health 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. Alternative treatments for nasal blockages, such as nasal corticosteroids, can be prescribed in their place 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. It should always be remembered that nasal decongestants were formulated specifically for short term use.
Can the misuse of nasal decongestants negatively affect patients who have other health conditions?
Yes, it can. 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, and patients with diabetes. They are also contraindicated in pregnant women 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 also interact negatively with a wide range of prescription monoamine oxidase inhibitors (MAOIs) that are commonly 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.
- Graf P, Juto JE (1995) Sustained use of xylometazoline nasal spray shortens the decongestive response and induces rebound swelling Rhinology 33(1):14-7
- 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
- Ramey JT, Bailen E, Lockey RF (2006) Rhinitis medicamentosa J Invest All Clin Immunol 16(3):148-155
- 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
- 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
- Mitchell JL (1999) Use of cough and cold preparations during breastfeeding J Hum Lact 15:347-349