David Slotnick, M.D.
Decongestants are medications that help open the nasal passages of people who experience congestion due to common coldscommon colds, the flu or allergies.These drugs work by constricting the small blood vessels of the nose, which forces blood out of the vessels and opens the nasal passage, allowing people to breathe more easily. The two main types of decongestants used to treat colds are pseudoephedrine and phenylephrine.
Decongestants are available as stand-alone medications and in combination with other medications. Some of the decongestants offered in combination with other medications are used to treat colds and the flu. These include:
- Decongestant/antihistamine combinations
- Decongestant/analgesic (pain relief) combinations
- Decongestant/antihistamine/analgesic combinations
- Decongestant/antihistamine/anticholinergic (antispasmodic) combinations
Patients should not take decongestants (even over-the-counter versions) unless they have consulted a physician. Decongestants can cause dangerous interactions with certain medications and potentially complicate certain health conditions. Several types of side effects also are common with decongestant use, although most are not a cause for concern. Symptoms of overdose can be similar to the medication’s side effects, but are usually more severe.
Decongestants may be dangerous when used by certain populations, including pregnant and breastfeeding women, children and the elderly. For this reason, it is particularly important that people in these groups consult a physician before using any type of decongestant. Although decongestants are available in over-the-counter formulations, some no longer appear on store shelves. In January 2006, federal legislation took effect that mandated that all drug products containing the drug pseudoephedrine be kept behind the pharmacy counter. Pseudoephedrine is a major ingredient in making methamphetamine, a highly addictive illegal substance.
Decongestants are a type of medication capable of relieving many of the symptoms associated with common colds, the flu and allergies (e.g., sneezing, coughing, runny nose). They work by reducing congestion of the nose and sinuses. The two main types of decongestants used to treat these conditions are pseudoephedrine and phenylephrine.
Decongestants treat the symptoms associated with allergic rhinitis (hay fever), non-allergic rhinitis (colds and the flu), sinusitis and allergic conjunctivitis (eye allergies). They do not treat the underlying cause of the symptoms.
Decongestants work by affecting small blood vessels in the nose. These blood vessels often fill with blood and swell during bouts with a cold or the flu. This narrows the nasal passages and makes it difficult for a person to breathe. Decongestants cause constriction of the blood vessels, which forces blood out of the vessels and opens up the breathing passageways. Decongestants also allow the tissue in the inner eyelid to shrink, which reduces eye irritation.
Although decongestants are available in over-the-counter formulations, some no longer appear on store shelves. In January 2006, federal legislation took effect that mandated that all drug products containing the drug pseudoephedrine be kept behind the pharmacy counter. Pseudoephedrine is a major ingredient in making methamphetamine, a highly addictive illegal substance. The goal of this legislation is to make it more difficult for people to obtain pseudoephedrine to make methamphetamine.
In addition, in 2000, the U.S. Food and Drug Administration (FDA) determined that the ingredient phenylpropanolamine, which has been used as a decongestant in various prescription and over-the-counter cough medications, is not safe for use. Research indicated that its use is associated with an increased risk of hemorrhagic stroke (bleeding in the brain).
To purchase decongestants with pseudoephedrine, a person needs to speak to a pharmacist, show a form of identification and sign a logbook. People are limited to purchasing 3.6 grams in a single day and 9 grams per month at a retail store. As a result of this change in the law, many drug manufacturers are removing pseudoephedrine from their decongestant medications.
Types and differences of decongestants
There are several different types of decongestants available in several forms, including:
- Eye drops
- Nasal spray
Most nasal spray decongestants work very quickly (in about 10 minutes) and can help to reduce nasal congestion for up to 12 hours. Nasal sprays only affect the areas of the nose and sinuses, limiting the number and severity of potential side effects (which may include a stinging or burning sensation within the nose or nosebleeds).
Oral (taken by mouth) decongestants begin to work in about 30 minutes and some can reduce nasal congestion for up to 24 hours. Oral forms of the medication cause blood vessels to constrict throughout the body, which can reduce the medication’s effectiveness and are more likely to cause adverse side effects (such as increased blood pressure or difficulty urinating).
In addition, decongestants used to treat colds and flu are often available in combination medications. Such combinations include:
- Decongestant/antihistamine combinations. These drugs are used to treat a stuffy nose, runny nose and sneezing. The antihistamine inhibits effects of the natural body chemical histamine (which causes inflammation and narrows the airways), while the decongestant constricts blood vessels, reducing nasal congestion.
- Decongestant/antihistamine/analgesic (pain relief) combinations. These drugs provide the same treatment response as antihistamine/decongestant combinations, but also add an analgesic that helps relieve fever, headache, as well as aches and pains associated with colds and the flu. Decongestant/analgesic combinations also are available that do not include the antihistamine effect.
- Decongestant/antihistamine/anticholinergic (antispasmodic) combinations. These drugs provide the same treatment response as antihistamine/decongestant combinations, but also add an anticholinergic that produces a drying effect in the nose and chest.
Most decongestants are available over-the-counter (OTC) and although there are several different brands available, all contain similar medication that works in the same manner.
Decongestants in common use include:
|Generic Name||Brand Name(s)|
|Mucinex-D Extended Release (decongestant|
|Naphazoline||Allerest, Clear Eyes, Naphcon|
Some common decongestant/antihistamine combinations include:
|Generic Name||Brand Name(s)|
|Chlorpheniramine and Pseudoephedrine||Allerest Maximum Strength Chlor-Trimeton Colfed-A Deconamine Kronofed-A Kronocaps Novafed A PediaCare Cold Formula Pseudo-Chlor Rescon Tanafed|
|Chlorpheniramine, Pyrilamine and Phenylephrine||Atrohist Pediatric Suspension Dye Free R-Tannamine Triotann|
|Brompheniramine and Pseudoephedrine||Bromadrine TR Bromfed Bromfenex Iofed Lodrane Respahist ULTRAbrom|
Some common decongestant/analgesic combinations include:
|Generic Name||Brand Name(s)|
|Pseudoephedrine and Acetaminophen||Actifed Sinus Daytime Coldrine Dristan Cold Sudafed Sinus Without Drowsiness Tylenol Sinus|
|Pseudoephedrine and Ibuprofen||Advil Cold & Sinus Motrin IB Sinus|
Some common decongestant/antihistamine/analgesic combinations include:
|Generic Name||Brand Name(s)|
|Chlorpheniramine, Pseudoephedrine and Acetaminophen||Actifed Cold & Sinus Alka-Seltzer Plus Cold Medicine TheraFlu/Flu & Cold Medicine|
|Diphenhydramine, Pseudoephedrine and Acetaminophen||Tylenol Flu NightTime Medication|
|Dexbrompheniramine, Pseudoephedrine and Acetaminophen||Drixoral Cold & Flu|
Some common decongestant/antihistamine/anticholinergic combinations include:
|Generic Name||Brand Name(s)|
|Chlorpheniramine, Phenylephrine, and Methscopolamin||AH-chew D.A. Chewable Dallergy Dura-Vent/DA Extendryl Mescolor OMNIhist L.A. Stahist|
It is very important not to exceed the recommended dose of any medication, including OTC drugs. Follow all directions on the package and contact a physician if there are any questions about the medication or its effects. OTC medications with ephedrine and pseudoephedrine may be kept behind the counter – rather than on store shelves – because of widespread abuse of these drugs. It may be necessary to ask a store clerk or pharmacist for assistance when purchasing these medications. Some stores may also require the customer to be 18 years of age or older.
Conditions treated with decongestants
Decongestants are prescribed to relieve symptoms associated with a variety of conditions, including:
- Viral infections (e.g., colds, the flu). Decongestants may be used in combination with analgesics (pain relievers) or cough suppressants to help relieve symptoms such as a stuffy nose and cough.
- Bacterial infection. Decongestants may be prescribed to patients with bacterial infections, such as certain types of ear infections that involve a bacterial infection of the middle ear or eardrum. Although these conditions may require antibiotics to fight infection, symptoms can sometimes be treated with a decongestant.
- Allergic rhinitis (hay fever). Inflammation of the mucous membrane that lines the nose caused by an allergic reaction. Decongestants treat the runny nose and congestion that are among the most common symptoms of allergic rhinitis.
- Non-allergic rhinitis. Inflammation of the mucous membrane that lines the nose. Though caused by viruses rather than contact with allergens, this condition has many of the same symptoms associated with allergic rhinitis.
- Allergic conjunctivitis (eye allergies). Inflammation of tissues inside the lining of the eyelid can often be reduced with the use of decongestants (usually administered through eye drops).
- Sinusitis. Inflammation of the lining of the sinus cavities in the face often leads to nasal congestion and a runny nose. Decongestants help reduce swelling of the mucous membrane lining the nose and decrease mucus production.
- Snoring. The nasal passageway often becomes obstructed with mucus during sleep, causing snoring to occur. Decongestants can help open up the nasal passageway and temporarily reduce snoring.
Conditions of concern with decongestants
Decongestants can cause dangerous interactions with certain medications and potentially complicate certain health conditions. Patients should not take decongestants (even over-the-counter versions) unless they have consulted a physician. Patients should be particularly careful if they have been diagnosed with or are being treated for any of the following conditions:
- Asthma. Condition in which the airways become blocked or narrowed, leading to breathing difficulties. Decongestants are never recommended for asthma treatment and can actually trigger an asthma attack in some individuals.
- Allergies. People with allergic reactions to decongestants or other ephedrine-based products, as well as any other allergies (including allergies to other medications, food, pollen and dyes).
- Heart disease. Refers to many types of diseases or conditions of the heart, which usually result from an inadequate flow of blood to the heart muscle. The elevated blood pressure that sometimes results from decongestant use can complicate this condition.
- Arrhythmias (abnormal heart rhythms). Decongestants can exacerbate this condition.
- Hypertension (high blood pressure). Because decongestants can lead to elevated blood pressure, hypertensive individuals should avoid decongestants when possible.
- Diabetes mellitus. Condition characterized by the body’s inability to use blood glucose for energy. Decongestants can cause an elevated blood glucose level, further complicating the condition.
- Enlarged prostate. Condition in men that causes the prostate to grow large enough to press on the urethra and interfere with urination. Decongestants can cause men with this condition to have trouble urinating.
- Glaucoma. Disease that affects the optic nerve and causes loss of vision. The condition also causes elevated pressure inside the eye. Decongestants can raise blood pressure, worsening this condition.
- Raynaud syndrome. A type of disease of peripheral blood vessels in which spasms in the small arteries in the hands and feet cause a restriction in the flow of blood to the fingers and toes. As a result, the fingers and toes turn whitish, then cold, and eventually blue.
- Thyroid problems. Problems caused when the thyroid gland is producing too much or too little of the hormones used to regulate the body’s metabolism. The use of decongestants can exacerbate this condition.
- Kidney disease. The use of decongestants in patients with kidney disease can increase the risk of adverse side effects from the medication. Patients with kidney disease may require a different dose.
Potential side effects with decongestants
Several types of side effects are common with decongestant use. These are not usually a cause for concern. However, if these side effects worsen or become problematic, patients should contact a physician.
Decongestants are chemically related to the hormone adrenaline, the natural decongestant in the body that is also a stimulant. As a result, decongestants often make people feel jittery, nervous, excitable or restless. People who use these medications also may experience a blood pressure increase and insomnia.
Other side effects associated with decongestants include:
- Difficulty urinating in men (due to enlarged prostate gland)
- Dizziness and drowsiness
- Dry or irritated nose and nosebleeds
- Loss of appetite
More serious side effects are occasionally experienced with decongestants. Patients experiencing these side effects should immediately inform their physician:
- Palpitations (rapid, irregular beating of the heart)
- Tremors (shaking or trembling)
- Very high blood pressure
In addition, some people may be at increased risk of a stroke (an event in which blood flow to the brain is restricted) when taking oral decongestants. Although the U.S. Food and Drug Administration (FDA) determined in 2000 that the ingredient phenylpropanolamine is not safe for use, people may still have expired decongestants at home that contain this substance. Phenylpropanolamine constricts blood vessels and also acts as a stimulant. It has been linked to an increased risk of hemorrhagic stroke (bleeding in the brain) in certain patients.
It is extremely important not to exceed the recommended dosage of any over-the-counter or prescription decongestant. One of the most commonly experienced side effects results from overusing decongestant nasal sprays. Rebound congestion (rhinitis medicamentosa) occurs when a decongestant nasal spray is used for too long (usually longer than three to five days). The condition is characterized by nasal swelling and congestion, which can make the condition difficult to detect as these are often the same symptoms that are being treated. To avoid rebound congestion, individuals using nasal spray decongestants should closely follow the directions on the label and discontinue use after several days, as directed. Patients should contact their physician if there are any questions about a medication’s dosage level or potential side effects.
Drug or other interactions with decongestants
Patients should consult their physician before taking any additional prescriptions, over-the-counter medications, nutritional supplements or herbal medications. Of particular concern to individuals taking decongestants are:
- Beta blockers. Drugs that help to control blood pressure by interfering with epinephrine (hormone used to increase blood pressure). Decongestants can interfere with these medications, reducing their effectiveness and increasing the chance of side effects.
- Monoamine oxidase (MAO) inhibitors. These drugs are frequently used to slow the breakdown of certain neurotransmitters (chemicals in the brain) and are used to treat depression. Using a decongestant within two weeks of a MAO inhibitor can increase the risk of serious side effects.
- Cocaine. Using cocaine and decongestants together can interfere with heart function, potentially causing irregularities. Their combined use also increases the chance of developing adverse side effects.
- Caffeine. Using caffeine with a decongestant can cause some of the potential side effects of decongestants (e.g., heart palpitations, tremors) to worsen.
- Diet pills. Taking diet pills with a decongestant can increase stimulation of the central nervous system and other side effects of the diet aids.
Other medications that may interact poorly with decongestants include:
- Asthma medications
- Seizure disorder medications
Many cold and flu medications that contain decongestants also contain other drugs, such as antihistamines or anticholinergics (antispasmodics). Patients are urged to consult their physician about the potential interactions that these other substances may have with medications the patient takes regularly.
Symptoms of overdose with decongestants
Symptoms of overdose can be similar to the medication’s side effects, but are usually more severe. A severe overdose can result in a coma or death. Patients exhibiting any of these symptoms should contact their physician immediately:
- Extreme fatigue
- Slow heartbeat
When decongestant nasal sprays are used more frequently or longer than recommended (usually more than three to five days), rebound congestion (rhinitis medicamentosa) can result. This condition usually consists of nasal swelling and congestion, which are often the same symptoms the nasal spray was being used to treat. Once symptoms appear, they will often not subside even after nasal spray use is discontinued. For this reason, using nasal spray decongestants longer than directed can lead to a type of dependency. Individuals using nasal spray decongestants should be careful to follow the directions on the package and should use the sprays only when necessary.
Pregnancy use issues with decongestants
The U.S. Food and Drug Administration (FDA) has placed pseudoephedrine (the active ingredient in most decongestants) in risk category C. This means that although there are no studies linking the premature termination of pregnancy or birth defects to pseudoephedrine use in humans, there is evidence of an increased risk in some animal studies. Pregnant women should not take pseudoephedrine without first consulting their physician. In addition, women who become pregnant while taking the drug should alert their physician immediately. The American Academy of Pediatrics approves the use of pseudoephedrine in breastfeeding women because the drug is secreted into breast milk in very low doses (less than 1 percent). However, pseudoephedrine is believed to cause a decreased milk supply in some breastfeeding women. Women who experience this effect should drink plenty of fluids in compensation and consult their physician with any concerns.
Child use issues with decongestants
Decongestants can sometimes make children jittery because the drug is closely related to the hormone adrenaline. In particular, small children and infants are susceptible to this effect. In addition, decongestant nose drops given to infants can result in too much of the medication being absorbed through nasal membranes. Most physicians agree that decongestants should not be used in children under the age of 6 months. Older children should only be given decongestants specially formulated for kids. To ensure their child receives the proper dosage of medication, parents should consult their child’s physician before providing any medication (including over-the-counter varieties) to their child.
Physicians will often recommend a nasal spray decongestant rather than an oral decongestant for children. This is because nasal sprays treat a limited area of the body, which reduces the amount of decongestant passed into the rest of the child’s body. This helps limit side effects.
It is very important that children understand that they should use nasal sprays only as directed. Using a spray longer or more frequently than directed can result in rebound congestion (rhinitis medicamentosa), which consists of nasal swelling and congestion. Some children may overuse their sprays unless carefully supervised.
Elderly use issues with decongestants
Although there have been no studies to evaluate the use of decongestants among the elderly, older users are generally believed to be more likely to experience adverse side effects when taking this type of medication. For this reason, physicians often recommend that users of decongestants – particularly medications that contain pseudoephedrine (a common ingredient in decongestants) – who are over age 60 use a short-acting form of the drug to reduce the risk of side effects. Older users should refrain from using a controlled-release or long-acting form of the drug.
Questions for your doctor about decongestants
Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions and treatments. Patients may wish to ask their doctor the following questions related to decongestants:
- Can you explain to me how decongestants work?
- What type of decongestant is best for me?
- How and when should I take this drug?
- How long can I safely use this drug?
- How will I know if the drug is working?
- What will be the next step if the drug fails to relieve my symptoms?
- How will this drug affect my current medical conditions other than allergies?
- How will this drug interact with other medications I am currently taking?
- What side effects should I inform you about?
- Can I take a decongestant if I am pregnant?