Not to be sniffed at: nasal decongestants

One of the joys of medicine is the continual expansion of science’s understanding of the human body and the ills which may affect it, coupled with the lifelong learning this necessitates the practicing clinician. This is often followed by crushing disappointment as our new knowledge triggers flashbacks to patients who clearly had this problem, we just didn’t realise it at the time.

And so it was with Alan. He came in with the simplest of problems – a blocked nose. He’d had it for a couple of months. It might have started with a cold, he wasn’t sure. He’d tried to manage it himself –he’d bought a nasal decongestant spray containing oxymetazoline and started using it once or twice a day. And it worked, his nose was clearer, he could breathe and sleep better at night, and he was going to stop it after a week, just like it said on the packet, but things started to get worse when he cut back, so he kept going. Now it’s been a month on the spray and he’s finally got an appointment with you.

Concerns around prolonged use of topical nasal decongestant sprays and drops are not new – we have long counselled our patients against using these continuously for more than a week. So, last week’s Medicines and Healthcare Products Regulatory Agency’s Drug Safety Update about nasal decongestant sprays and drops seemed unlikely to be a particularly insightful or interesting document, but I was surprised that it recommended a significant change to the recommended duration that clinicians will need to be aware of – patients should not use these treatments for more than 5 days (this had always been the recommendation for children but adults has been allowed up to 7 days) - and mentioned a condition I’d never heard of before:rhinitis medicamentosa. My Latin is virtually non-existent but even I could work out the likely origins of this rhinitis.

We all know about nasal decongestant rebound congestion: temporary swelling of the nasal passages, which may occur with oxymetazoline or xylometazoline-containing treatments when used heavily or for prolonged periods (even just 5 days it would seem). 

Rhinitis medicamentosa is more than this. The exact pathophysiology is unclear (indeed even as recently as 2013 European head and neck experts were questioning whether it was a genuine condition at all), but it seems reasonable to consider it almost as an extension of rebound congestion, where prolonged treatment use drives more severe nasal congestion plus visible changes to the nasal mucosa, and even lead to irreversible structural changes necessitating surgery. Patients may also describe itching in the nose, sneezing and rhinorrhoea, but unlike many other causes of rhinitis the symptoms are isolated to the nasal passages.

It is easy for patients to fall into this trap as these medications rapidly cause tachyphylaxis – the development of drug tolerance due to decreased response, often leading to a cycle of escalating use and, ultimately, dependency. 

Treatment would seem obvious: stop the causative agent, but the MHRA suggests recovery can take up to a surprisingly long 3 months and patients may need a tailored treatment plan, including gradual withdrawal of the decongestant, use of alternative therapies and clinical follow up to monitor recovery. 

Data is lacking on the best approach, however recent guidance from NHS Greater Glascow and Clyde suggests considering ‘a 2 month course of topical nasal steroids while stopping the topical decongestant after 1 month’. Some other sources suggest immediate cessation of the decongestant.

Back to Alan then. We can taper his decongestant nasal spray, replacing it with mometasone for a couple of months. Unfortunately, things fail to improve. Examination of his nasal passages with the limited tools we have in general practice, is unremarkable. 

But there was one more thing reading around this subject reminded me – other medications can also cause drug-induced rhinitis, including many anti-hypertensives and NSAIDs, especially ACE inhibitors, through the same process that drives cough.

Alan recently started ramipril for hypertension. Switching him to losartan solves the problem. Medicine is always full of surprises, even something simple as a blocked nose.

While we’re on the subject of lifelong learning, Friday 29^th May we have our live online Advanced Clinical Practice Update course. If you are an advanced nurse, paramedic, pharmacist, physiotherapist or physician associate in primary or urgent care looking to update your clinical knowledge, this is the perfect course for you. Find all the details on www.nbmedical.com.