Many people use over-the-counter nasal decongestant sprays when allergies and hay fever make them stuffy, congested and miserable, but if they use them beyond three consecutive days, they may run into greater breathing difficulty and damage to their nose.
Millions of Americans in pursuit of a remedy for stuffy nose and sinus pressure turn to over the counter (OTC) nasal sprays because of their quick action, availability and presumed safety.
But did you know prolonged use of topical nasal decongestants (TNDs) often leads to addiction?
Case in Point: A 32-year-old male was referred to me because of complaints of chronic nasal blockage. The patient suspected his problem was hay fever (allergic rhinitis). During the interview, he revealed that a year ago he began to have trouble sleeping because of a stuffy nose. He felt considerably better after using a TND before going to bed. Within 2 weeks he began to awaken in the middle of the night requiring another dose of his nasal spray for relief. One month later he required doses 4 times daily in order to avoid severe nasal congestion. By the time I saw him, he was going through almost a bottle of nasal spray daily. His diagnosis was Rhinitis Medicamentosa (RM) which means nasal inflammation (rhinitis) from medication (medicamentosa).
Topical nasal decongestants are surface active, liquid medications (Afrin, Neosynephrine, Zicam Extreme Congestion are some examples), which, after being sprayed into the nose, cause small arterial blood vessels in the lining of the nose to constrict. The nasal congestion rapidly decreases within minutes leaving the nose more open and somewhat dry. Long acting formulations of TNDs initially last for 12 hours. Early on, people think they have discovered the cure for their sinus problems. Little do they know as they continue to use the nasal spray beyond five days, the risk of addiction soars.
Is this like a drug addiction?
According to the National Institute on Drug Abuse, the definition of addiction is "a chronic, often relapsing brain disease that causes compulsive drug seeking and use despite harmful consequences to the individual that is addicted and to those around them. Drug addiction is a brain disease because the abuse of drugs leads to changes in the structure and function of the brain."
Addiction to topical nasal decongestants doesn't change the structure of the brain the way cocaine or heroin do, but habitual use of the TND leads to compulsive use and, eventually, physical damage to the user, as I'll explain below.
TNDs rapidly reduce nasal congestion but what goes wrong?
As TNDs are used beyond the recommended number of days (recommended to use for only three consecutive days) receptors (antenna-like sensors) on the arteries down regulate. This means they decrease in number. The duration of the decongestant effect of the nasal spray gets shorter as use continues (in other words, the spray doesn't work for as long as it used to). The shorter duration of benefit (nose feeling open and clear) often leads to more frequent use. The rebound congestion that occurs as the benefit of the spray wears off is often intense. At this point the TND user often experiences total nasal blockage (no air is able to be breathed through either nostril). Stopping the TND is not an option because of rapid return of plugged nasal passages. Increased mouth-breathing overnight may cause the throat to become dry and irritated.
How is Rhinitis Medicamentosa treated?
A doctor visit is required to confirm this diagnosis and initiate treatment. There are different ways to treat RM. Some physicians have used a weaning method that entails gradually weaker doses of the TND over several days.
My preference is to prescribe a short course of oral steroid which is tapered (reduced gradually) every two days for a total of ten days. A nasal steroid spray is prescribed for long-term use. The nasal steroid sprays are not addictive and may help to maintain good airflow through the nasal passages as the oral steroid is eliminated. The patient is instructed to stop the TND within two days, allowing time for the oral steroid to take effect. If there is no history of blood pressure elevation, heart, thyroid or eye problems, an oral decongestant (e.g. Sudafed) may also be recommended. I also recommend nasal saline rinses.
Rhinitis medicamentosa typically responds to treatment, but some patients end up going back to chronic use of TNDs after a period of weeks or months.
Are there long-term risks of Rhinitis Medicamentosa?
Yes, the nasal lining may become atrophied over time. Atrophy is scarring of the inside lining of the nose, which may cause irritation, bleeding and over drying. Rarely, erosion of the lining is so bad that septal perforation occurs (that's a hole in the mid wall of the nose that separates one nostril from the other). Nasal surgery may be required when the damage is severe.
How do you prevent Rhinitis Medicamentosa?
Try to avoid using TNDs. If you decide to try them, restrict usage to 3 days or less (even then, only do that a few times a year). See your doctor for advice on treating chronic nasal congestion. See an allergist if the problem is moderate to severe, or tends to recur more than once a year. Thoroughly read labels of all OTC, herbal and other alternative medications. Some of these products have the name of the decongestant embedded in a listing of natural ingredients.
Check the ingredients list for:
These are ingredients you want to avoid.
How is my patient doing (Case in Point)? He has not used TND for over a year and is very pleased with his response to nasal steroid spray and nasal saline rinses.
Do you suspect your OTC nasal spray has TND in it?
Have you had difficulty in stopping an OTC nasal spray?
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Dr. Thompson is a board-certified allergist and belongs to a large single specialty group in downtown Chicago, and south Chicago suburbs. He has been in practice for 18 years and has conducted clinical research and published papers on asthma and allergy problems. Visit his blog: www.allergy-asthmacorner.com