Decongestant treatments - what are the options and what works best?

Stuffy and runny noses are frustrating hallmarks of the common cold. Nasal sprays that tackle both symptoms simultaneously can provide relief and help people get back to their normal activities.

A bizarre paradox of the common cold is it not only causes congestion but often leads to a runny nose too. These contrasting yet simultaneous symptoms make for a pretty miserable few days.

Patients are left scratching their heads about what will provide relief. This is a conundrum pharmacists are often asked about, particularly during autumn and winter when cold and flu viruses become more of a problem.

The key role of pharmacists

Community pharmacists are more important than ever. Pharmacies should be the first port of call for any minor ailments, including cold and flu. Recommending over-the-counter products can also prevent patients from requesting unnecessary antibiotics, which is vital for curbing the growing problem of antimicrobial resistance.

Before recommending a decongestant, look for any red flags that would require immediate referral to a GP or another healthcare professional. This is particularly important if the patient says they've been experiencing symptoms for longer than a week.

Relieving nasal congestion and rhinorrhoea

Cold and flu are ultimately self-limiting conditions that improve with time. However, there are various different options for treating nasal congestion and rhinorrhoea, depending on the cause. They include:

• Self-care remedies, such as using a humidifier at home, or steam inhalation.

• Nasal saline irrigation. This can be delivered as sprays, rinse bottles (eg, NeilMed®), via a neti pot, or simply made up as a solution and then sniffed. This is a low-risk, non-medicated intervention. It is recognised as a useful treatment for chronic rhinosinusitis, although conclusive evidence of benefit in acute rhinosinusitis is limited.¹

• Decongestants (intranasal or oral). As monotherapy, these can improve nasal congestion in acute rhinitis in adults, but there is little evidence to support their use in children.² Oral decongestant-antihistamine-analgesic combinations seem to provide some overall symptomatic benefit when used in adults and older children with the common cold.³

• Intranasal corticosteroids. These have some benefit when used for acute sinusitis⁴, and are useful for treating allergic rhinitis and chronic rhinosinusitis, but there is little evidence about their utility in treating symptoms of the common cold, though the existing evidence does not demonstrate any benefit.⁵

• Antihistamines (oral or intranasal). These are useful for treating allergic rhinitis, but have little-to-no effect on symptoms of the common cold as monotherapy.⁶ As detailed above, there is some limited evidence that combined antihistamine and decongestant preparations may be helpful.⁷

• Intranasal anticholinergics (ipratropium bromide) appear to be helpful for reducing rhinorrhoea in chronic rhinitis, although with limited or no effect on nasal congestion.⁸

Choosing decongestants

For patients seeking short-term relief from nasal congestion, particularly in the context of a cold, decongestants are often a suitable option.

Decongestants are available as intranasal and oral forms. There is little clear evidence to support the use of one over the other.⁹ Intranasal decongestants tend to produce a more rapid onset of symptom relief, whereas oral decongestants tend to produce a longer duration of action.¹⁰

Decongestants available in the UK include:

• Ephedrine (as oral preparations or nasal drops).

• Pseudoephedrine (as oral preparations).

• Phenylephrine (as oral preparations).

• Oxymetazoline (as a nasal spray).

• Xylometazoline (as nasal drops or sprays).

Decongestant preparations come as monotherapy or in combination with other drugs. Oral decongestant-antihistamine-analgesic combinations seem to provide some overall symptomatic benefit in adults and older children with the common cold.³

One preparation combines xylometazoline (a decongestant) with ipratropium (an anticholinergic) in a nasal spray. There is some limited evidence that this combination may be superior at treating both nasal congestion and rhinorrhoea in people with the common cold.¹¹

Using decongestants safely

Intranasal decongestant use should be limited to a maximum of 7 days' duration, as prolonged use can lead to rebound congestion (rhinitis medicamentosa). This does not occur with oral decongestants; however, side-effects usually limit long-term use.¹²

Decongestants exert their effect through vasoconstriction of vessels in the nasal mucosa, but they can potentially cause systemic vasoconstriction and may lead to elevated blood pressure as well, though the clinical significance of this is unclear.¹³ Nasal decongestants are probably less likely to cause this than oral decongestants, although they can still be systemically-absorbed. They should be used cautiously in people with a history of cardiovascular disease or hypertension, and are contra-indicated in people with severe or uncontrolled hypertension.¹⁴

There is a potential for misuse of ephedrine and pseudoephedrine, which can be used recreationally, but may also be used in the illicit manufacture of methamphetamine. The MHRA has set restrictions on the amount of ephedrine and pseudoephedrine that can be sold or supplied without prescription, and recommends that pharmacists remain aware of the potential for misuse.¹⁵

The MHRA reported in February 2024 that there have been very rare reports of posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) associated with pseudoephedrine use.¹⁶

PRES is also known as reversible posterior leukoencephalopathy syndrome (RPLS). This is a rare condition in which parts of the brain are affected by swelling - usually as a result of an underlying cause. Symptoms include headache, changes in vision, and seizures, with some developing other neurological symptoms such as confusion or weakness of one or more limbs. Most patients fully recover.

RCVS is a neurological disorder. There is a sudden onset of severe headache associated with narrowing of the intracranial blood vessels. On brain imaging the narrowing of the blood vessels can look similar to a “string of beads”. Very rarely, RCVS can present as a medical emergency with strokes (ischaemic strokes or bleed), seizure or as brain oedema. Usually, the narrowing resolves by itself - reversible - within three months, and most patients fully recover.

The MHRA stated that:

- Pseudoephedrine is for short term use only and should only be used to relieve symptoms of nasal and sinus congestion in colds, flu, and allergies.

- No one should take pseudoephedrine if they have hypertension or hypertension not controlled by their medicines, or if they have severe acute or chronic kidney disease or kidney failure.

- Patients who develop symptoms of PRES and RCVS should stop taking pseudoephedrine immediately and seek urgent medical attention. These include severe headache that develops very quickly or suddenly feeling sick or vomiting, confusion or experiencing seizures or changes in vison.

An overview

As the first point of contact for many patients with cold and flu symptoms this winter, pharmacists have access to a range of products they can recommend to manage and minimise symptoms.