Understand the Effects of Topical Nasal Decongestants on Blood Pressure

Nasal congestion is a symptom often associated with the common cold and allergic rhinitis, and it is commonly treated with decongestants. In the US, pseudoephedrine is a commonly used systemic decongestant. Topical nasal decongestants, including oxymetazoline and phenylephrine, are other treatment options. Because decongestants act by constricting blood vessels, their use can be problematic in individuals who have hypertension. Although this may be a valid concern for systemically acting decongestants, a question that arises is whether topical nasal decongestants also raise blood pressure.

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Background

Pseudoephedrine and oral phenylephrine are 2 systemically acting decongestants that have been available OTC. In September 2023, the FDA’s Non-prescription Drugs Advisory Committee concluded that available data do not support the use of orally administered phenylephrine as a nasal decongestant at the dosage noted in the OTC cough-cold monograph. Neither the FDA nor the Committee had concerns about the safety of taking oral phenylephrine.¹ Oxymetazoline and phenylephrine are topical decongestants that are also available OTC. The Advisory Committee’s findings are not applicable to topical phenylephrine.

Pseudoephedrine is an alpha- and beta-adrenergic agonist that causes vasoconstriction in the nasal mucosa, thus relieving congestion.² The systemic effects of pseudoephedrine include increased systolic blood pressure, increased heart rate, and bronchial relaxation.² Due to its cardiovascular effects, patients with hypertension are warned about the possibility of increased blood pressure while taking pseudoephedrine.² Oxymetazoline is an alpha-adrenergic agonist that, when administered intranasally, constricts the arterioles, which decreases nasal congestion by restricting blood flow to the nasal mucosa.³ Similarly, phenylephrine is a potent, direct-acting alpha-adrenergic agonist that produces local vasoconstriction, resulting in nasal decongestion.⁴ Local adverse effects that may be experienced by patients using topical decongestants include nasal discharge, sneezing, and irritation in the nasal cavity.^3,4

Topical Decongestants and Blood Pressure

To examine whether topical nasal decongestants produce systemic cardiovascular effects, namely elevated blood pressure in adults, we conducted a literature search using PubMed and Google Scholar. The search included various combinations of the following terms: blood pressure, hypertension, and topical nasal decongestants. Filters were applied for randomized control trials conducted in humans.

A single-center, double-blind, placebo-controlled study conducted by Mayo Clinic evaluated 68 adult patients with no history of hypertension who were being treated with intranasal vasoconstrictors for epistaxis in the emergency department.⁵ A cotton ball soaked with either oxymetazoline, phenylephrine, lidocaine with epinephrine, or saline, was placed in each patient’s nostril and clipped in place for 15 minutes. The primary outcome in this study was the largest increase from baseline in mean arterial pressure in each treatment group compared to the saline arm. Secondary outcomes measures were an increase from baseline in systolic blood pressure, diastolic blood pressure, and heart rate. Hemodynamic measurements were taken at baseline, 5 minutes after administration of a single dose of treatment or placebo, and every 5 minutes over a 30-minute observation period. Researchers found no greater increase in mean arterial pressure in any of the treatment groups compared to the saline group. There were also no statistically or clinically significant differences in the secondary outcomes between the treatment and placebo groups. As such, the researchers concluded that topical intranasal vasoconstrictors do not significantly increase blood pressure in patients who do not have hypertension.⁵

An observational study performed in India by Rehan et al. examined the effects of various decongestants on heart rate and blood pressure.⁶ Researchers randomly asked patients leaving an otorhinolaryngologist's office with a prescription for decongestants to participate in their study. Through this process, 100 patients were identified and evaluated. These patients were prescribed either phenylephrine, pseudoephedrine, phenylpropanolamine, oxymetazoline, xylometazoline, or combinations of 2 of these medications. Seven of the patients received oral and topical nasal decongestants concurrently and only 2 patients received a single topical nasal decongestant. The researchers took baseline measurements of heart rate and blood pressure, followed by additional measurements on days 3 and 7 of treatment for each of the participants. The researchers did not report the duration of treatment for each patient. The primary outcome of the study was the increase in heart rate, systolic blood pressure, and diastolic blood pressure from the mean baseline measurements. The researchers noted a “significant rise in the [heart rate],” but a “slight insignificant rise” in systolic and diastolic blood pressure on day 7; the mean baseline heart rate was 80.79 beats/min and by day 7 it rose to 84.33 beats/min. Notably, the analysis did not differentiate the results between topical or systemic products.⁶

General Safety of Topical Nasal Decongestants

Intranasal decongestants are generally well tolerated because adverse effects are typically localized to the nasal passages, although prolonged or excessive use can cause irritation and lead to rebound congestion. Despite the findings of the studies reported above, manufacturers warn that oxymetazoline and phenylephrine should be used with caution in patients with cardiovascular disease or in those with uncontrolled hypertension. Patients taking monoamine oxidase inhibitors or tricyclic antidepressants should avoid using topical nasal decongestants because concurrent use can alter the therapeutic effect of the alpha-adrenergic agonist.^7,8

Conclusion

Patients with underlying hypertension should be cautioned about the use of oral decongestants; topical nasal decongestants might be safer. Based on the studies reviewed, topical nasal decongestants are not expected to cause a significant elevation in blood pressure. Notably, however, only 2 studies were reviewed so the evidence is limited both in quantity and quality and thus we are unable to offer a definitive conclusion on this question. The use of topical nasal decongestants is likely safe for most patients with hypertension; nonetheless, patients who wish to use topical decongestants must be advised to check with a pharmacist or physician prior to using these products and to monitor their blood pressure while using these medications.

References

1. The Current Status of Oral Phenylephrine as a Nasal Decongestant with Dr. Theresa Michele and Dr. Ilisa Bernstein. FDA. March 19, 2024. Accessed May 20, 2024. https://www.fda.gov/drugs/news-events-human-drugs/current-status-oral-phenylephrine-nasal-decongestant-dr-theresa-michele-and-dr-ilisa-bernstein

2. Pseudoephedrine. UpToDate Lexidrug. Updated May 7, 2024. Accessed May 20, 2024. http://online.lexi.com

3. Oxymetazoline Hydrochloride. UpToDate Lexidrug. Updated April 24,2024. Accessed May 20, 2024. http://online.lexi.com

4. Phenylephrine (Nasal). UpToDate Lexidrug. Updated May 4, 2024. Accessed May 20, 2024. http://online.lexi.com

5. Bellew SD, Johnson KL, Nichols MD, Kummer T. Effect of Intranasal Vasoconstrictors on Blood Pressure: A Randomized, Double-Blind, Placebo-Controlled Trial. J Emerg Med. 2018;55(4):455-464. doi:10.1016/j.jemermed.2018.07.004

6. Rehan HS, Chopra A, Kumar S. To Study the Utilization Pattern of Nasal Decongestants and their Effects on Heart Rate and Blood Pressure. Journal. Clinical Rhinology: An International Journal. 2012;5(3):91-94.

7. Oxymetazoline Hydrochloride. Merative Micromedex. Updated March 8, 2024. Accessed March 8, 2024. https://www.micromedexsolutions.com

8. Phenylephrine Hydrochloride. Merative Micromedex. Updated March 4, 2024. Accessed March 6, 2024. https://www.micromedexsolutions.com