Decongestant Options For Sinus Infection

In our latest question and answer, the pharmacist discusses drug and non-drug options to treat congestion associated with a sinus infection.

Question

I recovered from COVID but my doctor fears that I developed sinusitis, so they prescribed amoxicillin (750 grams x 3/day for 5 days). I need to clear my nasal passage in the evening for sleeping. Decongestants cause rebound effects and saline sprays haven’t worked due to the severity of the nasal blockage. Is there a low dose/safer decongestant that will cause fewer issues with prolonged congestion?

Asked by Cindy On Jan 09, 2022

Answered by
Medical Content Reviewed By HelloPharmacist Staff

On Jan 10, 2022

Key points

  • There are several over-the-counter decongestant options.
  • These options include nasal sprays like Afrin and Neo-Synephrine, saline nasal sprays like Ocean, and oral drugs, like Sudafed.
  • Each type of decongestant has positive and negatives.
  • Only topical decongestants, like Afrin and Neo-Synephrine, are thought to cause rebound congestion. Oral decongestants generally do not.

Hello and thanks for your question.

I'm sorry to hear that you went through having COVID and now are suffering from a sinus infection. I hope the amoxicillin starts helping soon!

In terms of decongestants, you certainly have a few options, but let's talk about rebound congestion first, since you mentioned it in your question.

Rebound Congestion

Rebound congestion (the medical term is rhinitis medicamentosa) can be very frustrating to experience and is essentially our body responding to the overuse of medication.

With continuous use of a decongestant, it starts to not work as well and requires more frequent dosing to experience the same congestion relief.

Over time, the congestion can get so bad, that it is worse than it originally was, and it isn't unheard of that people can become dependent on the decongestant to experience any relief.

So, I completely understand your concern about rebound congestion! However, not all decongestants are associated with it. The vast majority of studies show that only topical decongestants (i.e. nasal sprays) are associated with rebound congestion.

These products include:

Oral decongestants, including Sudafed (pseudoephedrine) and Sudafed PE (phenylephrine), generally do not cause rebound congestion.

One textbook on the subject puts it very plainly:

Oral decongestants do not cause rebound congestion but are not as effective as topical formulations.
Middleton's Allergy Essentials 2017, Pages 205-224

I want to point out here, that phenylephrine is available as both an oral drug (Sudafed PE) and topical (Neo-Synephrine and associated generics). Only the topical form is associated with rebound congestion.

In general, you don't want to use a topical decongestant for more than 3 to 4 days in a row. Doing so will put you at risk for rebound congestion, which, as mentioned, can make you feel more stuffed up than you originally were.

Decongestant Options

Nasal Spray Bottle

Let's go over all the over-the-counter decongestant options.

Oral Decongestants

First, you have the products you take by mouth:

Both drugs help relieve congestion, but the 'original' Sudafed (pseudoephedrine) is much more effective than Sudafed PE (phenylephrine).

Sudafed PE was brought to market to fill the gap that Sudafed left after the passing of the Combat Methamphetamine Epidemic Act, which requires pseudoephedrine products be sold behind the counter.

So, even though pseudoephedrine is technically an over-the-counter product, it is stocked behind the pharmacy counter as you need to show identification for it. You do not need to show identification for Sudafed PE.

As mentioned above, these oral decongestants don't cause rebound congestion, but they do have other precautions.

For example, you shouldn't use them if you have high blood pressure or problems with your heart. If you do, please check with your doctor first before taking them.

Topical Decongestants

Now, I know you want to avoid drugs that can cause rebound congestion, but let's list them here again:

These drugs are very effective and generally can reduce congestion within just a few minutes of use.

As I've written above though, they do cause rebound congestion if used for more than a few days.

There are other topical options too.

Sinus rinses, that contain salt (i.e. saline rinses) are increasingly popular.

There are several brand-name products that utilize saline. These include:

  • Simply Saline
  • Ocean Saline

Other products that utilize saline, along with a specialized delivery device, include:

  • Neti-Pot
  • NeilMed Sinus Rinse

With these last two products, an individual can make their own saline solution by adding salt on their own, or, from a pre-made pack.

Saline rinses do not cause rebound congestion, but generally, aren't quite as effective as the other topical decongestants, or oral ones either.

A quick note here on the 'strength' of saline rinses.

Depending on the concentration of the saline rinse, it can be hypotonic, isotonic, or hypertonic. These terms mean the following:

  • Hypotonic (concentration less than 0.9%)
  • Isotonic (concentration equal to 0.9%)
  • Hypertonic (concentration greater than 0.9%)

Hypotonic saline solutions are the most common of the saline rinses.

Most over-the-counter saline products are about 0.65%. They tend to be more moisturizing than the others. They are best used when you have very dry nasal passages.

Isotonic sale rinses are often used as a pure rinse, to flush out the nasal passages/cavity.

Hypertonic nasal sprays tend to help reduce swelling and are the best saline option to reduce congestion because they remove moisture from the nasal tissues.

Several studies show that hypertonic saline sprays are better at reducing congestion than other saline sprays, but tend to cause more side effects (which are mild, but include nasal irritation and nose bleeds):

HS [hypertonic saline] improves symptoms over IS [isotonic saline] nasal irrigation in treating sinonasal diseases. There is no difference in disease-specific quality of life. However, HS [hypertonic saline] brings greater minor side effects than IS [isotonic saline].
Am J Rhinol Allergy . 2018 Jul;32(4):269-279

Best Option?

The best decongestant for you really depends on your situation as all of the options have their positives and negatives.

Below are a few quick pros and cons of each:

Oral Decongestants

Fast, effective treatment

Relatively inexpensive

Easy Dosing

Do not cause rebound congestion

- Should not use if you have high blood pressure or a heart condition

- Sudafed (pseudoephedrine) must be purchased behind the pharmacy counter

Topical Decongestants (Drug Based)

Fastest relief of nasal congestion

+ Inexpensive

Can be messy to use

- Rebound congestion

- Can only use for 3-4 days in a row

Topical Decongestants (Saline)

Inexpensive

+ 'Non-drug' option

- Generally do not work as well as the 'drug' options

Can be messy to use

- Multiple product options can be confusing (e.g. isotonic, hypotonic, hypertonic)

Final Words

You mentioned in your question that you have tried saline sprays, but they don't work.

If you are concerned about the 'drug' options, I recommend trying a hypertonic saline spray. I'm not sure if that is what you used, but if not, you may find it more effective than a regular saline spray.

In terms of dosing for the oral decongestants, the usual dose of pseudoephedrine is 30mg to 60mg every four to six hours.

If it is safe for you to use an oral decongestant (i.e. you don't have any issues that are considered dangerous, like heart problems), I recommend starting on the low end and seeing how you respond.

Please let us know if we can be of any further help and thanks again for reaching out to us!

References

  • Middleton's Allergy Essential, ScienceDirect
  • Oxymetazoline Monograph, PubChem
  • Pseudoephedrine Monograph, PubChem
  • Phenylephrine Monograph, PubChem
  • An evaluation of nasal response following different treatment regimes of oxymetazoline with reference to rebound congestion, PubMed
  • Rhinitis medicamentosa: aspects of pathophysiology and treatment, PubMed
  • Hypertonic Saline Versus Isotonic Saline Nasal Irrigation: Systematic Review and Meta-analysis, PubMed

About the Pharmacist

Dr. Brian Staiger, PharmD

Dr. Brian has been practicing pharmacy for over 11 years and has wide-ranging experiences in many different areas of the profession. From retail, clinical and administrative responsibilities, he's your knowledgeable and go-to source for all your pharmacy and medication related questions!

Recent Questions