"Doc, it seems like I can't ever breathe out my nose. The pills help my sneezing but I always feel congested"
Many people identify with the above complaint. Nasal congestion is one of the most common symptoms of allergic and non-allergic rhinitis. "Rhinitis" means inflammation of the inside of the nose. Allergic rhinitis is caused by allergy triggers such as pollens from trees, grasses or weeds. Other allergy triggers include mold spores, dust mites, pets (cats and dogs head the list), feathers and, believe it or not, insects such as cockroaches. Non-allergic rhinitis may be triggered by weather changes, indoor or outdoor pollution, cigarette smoke or ash, fragrances, fumes and a host of other small particles in the air.
Why is nasal congestion so difficult to treat?
The inflammatory process that results in nasal inflammation (rhinitis) is very complex and involves several different cell types and substances released from these cells.
Therefore, different medicines use different methods to relieve congestion:
Antihistamines (such as Claritin, Zyrtec, Allegra) block the impact of histamine but fall short of reducing the effect of several other substances released from inflammatory cells during the allergic inflammatory response. They are more effective at drying the nasal passage and reducing itching and sneezing.
Oral decongestants (such as Sudafed) target nasal congestion and often successfully reduce symptoms of stuffy nose. Access to over-the-counter (OTC) decongestants is more difficult because of intense regulation of pseudoephedrine. It is kept behind the pharmacy counter, sold in small (and expensive) quantities and requires showing an I.D. and signature. Unfortunately, oral decongestants may elevate blood pressure, increase heart rate, cause insomnia, worsen glaucoma, aggravate thyroid disorders and complicate bladder and bowel problems (especially in the elderly).
Topical nasal spray decongestants are quick and effective at treating nasal blockage but if used for more than a few days may cause dependency (Rhinitis Medicamentosa).
Singulair is a leukotriene blocker and reduces the influence of leukotrienes which are substances released by some nasal inflammatory cells. It is commonly used as a controller for bronchial asthma but is also indicated for treatment of allergic rhinitis. In many clinical studies the combination of Singulair with an oral antihistamine has been more effective at treating allergic rhinitis compared to Singulair alone.
Topical antihistamine nasal sprays (such as Astelin, Astepro, Patanase) have provided allergists another alternative to address the shortcomings of conventional rhinitis treatment (antihistamine/decongestant plus nasal steroid spray). Some patients have benefitted from these nasal sprays. But clinical studies have shown inconsistent results regarding their impact on nasal congestion.
Intranasal steroid sprays (INS) (such as Flonase, Nasonex, Nasacort AQ, Veramyst) have the greatest impact on the cascade of inflammatory events that occur in the nose when rhinitis is active. Reduction of inflammation is crucial in the treatment of allergic and most forms of non-allergic rhinitis. Some people have difficulty with using INS. They require consistent use and are less effective if the nose is markedly obstructed.
What is the best way to treat problematic nasal congestion?
According to a review article in Allergy and Asthma Proceedings, May-June, 2008 Vol. 29, No 3 pg 232-240, intranasal steroids were the most potent allergy medications for treating all allergy symptoms including nasal congestion.
I think it is important to have an INS as the anchor in my treatment plan for the majority of my rhinitis patients. I use several different brands depending on what is covered by the patient's insurance, and their ability to comfortably use the device.
Proper nasal spray technique is very important (click here for more on this).
I also inform my patients about the importance of timing (using INS after the shower or bath, in order to have the nasal passages cleared out).
Consistent use (not missing doses) and when to back down or off the INS is also important to discuss.
Successful management of moderate to severe nasal congestion and other symptoms of rhinitis require a comprehensive evaluation with focus on trigger factors, environmental controls and other health problems that may contribute to the problem. See an allergy specialist if you continue to have unmet needs in the treatment of your nasal problems.