Special Considerations for Nasal Decongestants in Certain Populations

Cough and cold season is coming to an end, but allergy season is now upon us.

In the coming months, congestion will be a source of discomfort for many patients. One question that pharmacists are asked most frequently during allergy season is, “What is the best remedy for a stuffy nose?”

Pharmacists typically answer with a nasal decongestant, but with the strict regulations surrounding pseudoephedrine, many patients do not want to go through the hassle of buying the product separately at the pharmacy counter.

So, the next-best product to recommend is phenylephrine. Or is it?

Phenylephrine is among the most readily available and affordable OTC nasal decongestants. Nevertheless, studies have started to question its efficacy.

Phenylephrine is an adrenergic alpha-agonist that acts as a potent vasoconstrictor when given intranasally, opthalmically, topically, or intravenously. When given orally, however, the bioavailability significantly decreases to approximately 38% because of the drug’s extensive first-pass metabolism. Consequently, the vasoconstrictor effects of oral formulations of phenylephrine are greatly diminished.

Results of a recent study published in the Annals of Allergy, Asthma & Immunology showed no significant difference between placebo and phenylephrine in relation to a mean change in daily nasal congestion. In another study, a 40-mg dose of phenylephrine was deemed no more effective than placebo for congestion.

That brings us back to pseudoephedrine, and retail pharmacists often receive questions about its use in patients with high blood pressure.

Although hypertensive patients are strongly cautioned by many health care providers to avoid pseudoephedrine, only an approximately 1-mmHg increase in blood pressure has been seen in patients with controlled hypertension who use it. Therefore, it is safe to recommend pseudoephridine for patients with controlled hypertension, as long as they are monitoring their blood pressure regularly.

Nevertheless, hypertensive patients are only recommended to use pseudoephridine for the shortest duration possible, or approximately 3 days or less. If hypertensive patients choose to use pseudoephridine and their blood pressure increases, then an intranasal product is preferred.

Many patients with hypertension ask about products speficially marketed to them, such as Coricidin HBP. While these products may contain analgesics, expectorants, cough suppressants, and/or antihistamines, they do not contain decongestants, and so they will not help with congestion.

Other conditions that warrant special considerations for decongestant use include attention-deficit/hyperactivity disorder (ADHD), benign prostate hyperplasia (BPH), diabetics, narrow-angle glaucoma, children, and pregnancy.

Caution must be used in patients with ADHD because of the risk of palpitations. While they are not common, patients should consult their prescribers if they occurs.

Urinary retention can be problematic for patients with BPH. Because of this, intranasal products should only be used in this population.

For patients with glaucoma, intraocular pressure can increase while using decongestants, though they can be used cautiously and for a short duration.

Children younger than 2 years should never use decongestants. Clinical data are also lacking to support the safety and efficacy of decongestants in children younger than 6 years, and so they should not be recommended for use.

Because of decongestants’ associated risk for fetal harm, the products should be avoided during pregnancy. Decongestants should also be avoided in lactation because of the risk for infant irritability.

Reference

Meltzer EO, Ratner PH, McGraw T. Phenylephrine hydrochloride modified-release tablets for nasal congestion: a randomized, placebo-controlled trial in allergic rhinitis patients. Ann Allergy Asthma Immunol. 2016 Jan;116(1):66-71. doi: 10.1016/j.anai.2015.10.022. Epub 2015 Nov 7.