Revisiting Rhinitis Medicamentosa: Examining the Evidence on Topical Nasal Decongestants

Background: Over-the-counter topical nasal decongestants are effective and well-tolerated treatments for the temporary relief of nasal congestion, a symptom that can impair quality of life. Their duration of use is limited owing to potential for rhinitis medicamentosa (RM) or rebound congestion (RC), despite uncertainties around the clinical occurrence or onset of these phenomena. Objective: To investigate the clinical occurrence and onset of RM, RC or tolerance with topical nasal decongestants to inform evidence-based recommendation practices for pharmacists and ensure patients do not forego potentially beneficial treatments. Methods: A literature search was conducted with ProQuest to identify and synthesize evidence on RM, RC or tolerance with nasal decongestant sprays or drops. A respiratory specialist and community pharmacist provided clinical perspectives. Results: Eighteen articles were assessed, reporting 13 studies with oxymetazoline, five studies with xylometazoline. There was no evidence of RM or RC after 7 days with oxymetazoline (up to 400 μg total daily dose) or up to 10-days with xylometazoline (840 μg total daily dose). Well-designed studies suggested no occurrence of RM, RC or tolerance with up to 4 weeks of oxymetazoline. No studies evaluating naphazoline, phenylephrine or ephedrine were identified. Conclusion: Oxymetazoline and xylometazoline are highly effective at rapidly improving nasal congestion and have well-established safety profiles. Well-designed studies yielded no evidence of RM, RC or tolerance when used short-term at commonly recommended dosing and frequency. Since some patients may exceed the duration of use in the label, pharmacists can play a vital role in counseling patients on proper intranasal decongestant use and treatment duration.

Plain Language Summary

A blocked or stuffy nose is a common symptom of hayfever and colds that can make daily activities and sleeping difficult. Over-the-counter nasal decongestant sprays or drops work within a few minutes to ease a blocked nose and provide symptom relief. Some studies from around 30 years ago suggested that, when these medicines were used regularly for weeks or months, they might cause a condition called rhinitis medicamentosa, also known as rebound congestion (RC). This is where the lining of the nose swells leading to the nose feeling blocked when the medicines are stopped. We looked for other studies that investigated this effect to see when it might occur and if people developed tolerance to the medicines, meaning they needed to take more for them to work. We included information to help pharmacists treat patients with RC. We found 18 studies that looked at medicines containing xylometazoline or oxymetazoline. When people used these medicines for 7 days (oxymetazoline) or up to 10 days (xylometazoline) there was no evidence of RC. Some well-designed studies found no evidence for RC or tolerance with up to 4-weeks of oxymetazoline use. No studies were found for other medicines in nasal decongestants. When people use xylometazoline- or oxymetazoline-containing medicines as described in the patient information leaflet there is no evidence for RC or tolerance. Pharmacists can play an important role in making sure that patients know how to use the medicines properly, at the correct dose and for no longer than stated in the instructions.

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