Nasal spray decongestants, underrecognized limitations

Mr. Jones came into the office complaining of ongoing nasal congestion since his most recent cold. "Doc, it's been weeks, and I can't get my nose to clear up. The only relief I get is from this nasal spray, and it doesn't seem to do much anymore." He pulled the bottle of nasal spray from his pocket to show me. "But if I don't use it, I can't breathe."

In the throes of an illness, we reach for any and all potential remedies for a little relief, including the nasal spray decongestants conveniently found over the counter at our local pharmacy. Nasal spray decongestants, such as Afrin, work by constricting the blood vessels in the inflamed lining or mucosa of our nose and in so doing attempt to shrink the mucosa, open the passages and help us breathe.

In studies, however, the benefit after a single dose compared to placebo (the placebo always has some benefit, often significant) is only about a ten to fifteen percent improvement in reported symptoms, and this benefit quickly wanes with each subsequent dose. The nasal congestion returns, and after continued use of the spray for a few days, there is no benefit.

Of course, most illnesses last longer than three days, and therefore people find themselves continuing to use the spray. (To compensate and find some relief, people often then increase the frequency of sprays.) Unfortunately, after using the nasal spray for more than a few days, people suddenly discover on trying to stop that they can't.

Rebound Congestion

The mucosa in their nose is even more inflamed and their congestion is even more severe than if they had never used the spray. They have what is called rebound congestion.

People using nasal spray decongestants for prolonged periods of time essentially become addicted to the spray and not because of any 'high," but a stuffed nose from which a person struggles to breathe is truly frustrating.

Do not use this product for more than 3 days.

Many people believe that the warning labels on over the counter medications are meant to be taken with a grain of salt, if not ignored altogether, but that is short-sighted. The warning on the nasal spray decongestant labels can't be written in large enough letters. The sprays are simple over the counter (OTC) medications, but one of the greatest difficulties ENT (ear, nose & throat) doctors face in their practice is getting people off of them.

Names of nasal spray decongestants

The list below is a non-exhaustive list of over the counter nasal spray decongestants in this class and their active ingredients.

Active ingredients:

oxymetazoline - Afrin, Vicks Sinex
phenylephrine - Dristan, Neo Synephrine

What this class of sprays have in common is that they are adrenergic (like adrenaline - what is released into the blood on seeing a bear). While they are topical nasal sprays, there is always a degree of absorption, even if small, across the mucosa of the nose. As a result those with high blood pressure or otherwise predisposed to heart attacks or strokes are also instructed by the label not to use these nasal sprays.

Alternative OTC nasal sprays

Often forgotten saline (salt water) nasal sprays can be quite effective in relieving symptoms of nasal congestion and potentially decreasing the risk of sinus infections, as they moisten the mucus and allow the sinuses to keep draining. (A draining sinus is generally not an infected sinus.) A runny nose is merely a nuisance.

The truth about cold medicines

Despite the commercials for nasal spray decongestants and other cold medications and despite the fact that we live in a world of the internet, high definition TVs and portable telephones, there really is no great over the counter medication for a cold. None are tremendously better than placebo and none are without the potential for side effects. There is something to be said for being on some level accepting of a cold and the stuffy or runny nose that comes with it. If only we always have the luxury to be that patient.

More about cold medicines in a future entry..