You’ve probably had a stuffy nose before. It is common for people to use nasal decongestants to get rid of this annoying problem and while most of these medicines are dispensed over-the-counter (OTC), their potential side effects should definitely not be underestimated. In this article, we will discuss the use of nasal decongestants for sinusitis and the long-term risks for decongestant use.

What are Nasal Decongestants?

Nasal decongestants are a class of drugs that are used to treat stuffy nose (nasal congestion) and inflammation of the sinuses (sinusitis). When the nasal mucosa covering the inside of the nose and sinuses gets irritated, for instance by cold air, microbial infection, allergies, and irritating substances like cleaning agents, immune cells inside the mucosa get activated and start releasing inflammatory mediators, resulting in mucosal swelling and secretion of mucus. The combination of a swollen mucosa and mucosal plugging leads to blockage of the nasal passages, which can impair normal breathing, causing discomfort and sleeping disturbances.

Nasal decongestants are the most commonly used medications for treating sinusitis. They work primarily by activating adrenergic (adrenaline-sensitive) receptors of muscle cells inside mucosal blood vessels, narrowing them and reducing the thickness of the mucosa in the process, thus, opening the nasal passages and alleviating symptoms of congestion. As a comparison, you may have experienced a phenomenon of nasal congestion relief when exercising or facing emotional stress. That is because stress leads to the release of adrenaline which activates the same adrenergic receptors that decongestants target.

Nasal decongestants are primarily used locally in the nose in the form of sprays. Examples of such decongestants include xylometazoline, oxymetazoline, and tramazoline. The fine mist that sprays create helps spread the drug uniformly throughout the entire mucosa, thus, providing more coverage and better therapeutic effect. The local administration of medications usually reduces the systemic side effects that decongestants may have, they act similarly to adrenaline so you can imagine what those adrenergic receptors in the heart and blood vessels throughout the body can do when stimulated. Other decongestants like pseudoephedrine are primarily used orally. While some studies have shown that topical xylometazoline-containing decongestants are superior to orally administered pseudoephedrine in their decongestant effects, pseudoephedrine-containing drugs usually do incorporate other active substances as well (such as fever and allergy medications), which can provide an overall stronger therapeutic effect for complex conditions beyond just a stuffy nose, like allergies or infections.¹

How Can Decongestants Become Harmful?

Long-term use of decongestants has shown to cause harmful side effects, some of which can leave a lifetime scar to the unsuspecting person. Some of these side effects include rhinitis medicamentosa, loss of smell, nasal septal perforation, chronic laryngitis, and cardiovascular problems.

Rhinitis medicamentosa

Rhinitis medicamentosa (the medical term for drug-induced inflammation of the nose) is inflammation of the nasal mucosa caused by overuse of nasal decongestants, with time leading to rebound congestion. It is hypothesised that when adrenergic receptors in the nasal mucosa are activated for a prolonged time, they get “exhausted” and stop responding to stimulants. This phenomenon is known as tachyphylaxis and leads to progressive loss of decongestant effect and chronic nasal congestion despite continuous medication use. Due to chronic constriction of nasal blood vessels, the mucosa dries out and becomes easily irritated.²

Loss of Smell and Nasal Septal Perforation

Prolonged periods of nasal blood vessel constriction lead to restricted blood flow to the nasal mucosa. Restricted access to valuable nutrients and oxygen from blood leads to damage of the mucosal tissues, including the olfactory epithelium responsible for the sense of smell. Patients on long-term treatment with nasal decongestants have reported a decreased or absent sense of smell. Thankfully, this effect is reversible and patients regain their normal sense of smell when the decongestant is discontinued on time before irreversible tissue damage has occurred.

When decongestants are used for an extensive period, they can cause thinning of the nasal mucosa and weakening of the nasal septum - the wall separating the left nostril from the right nostril. With time, this can lead to the development of a hole inside the nasal septum which can impair normal airflow and cause consequent sleeping problems.³

Chronic Laryngitis

The nose and throat are anatomically connected to each other, and when we use topical nasal decongestants, some of the medication can flow down the throat and cause local side effects. By constricting blood vessels inside the mucosa of the voice box (the larynx), nasal decongestants can cause a chronic cough, feeling of a sore throat, and voice hoarseness.

Cardiovascular Problems

Other than in the nasal mucosa, adrenergic receptors can also be found in the heart muscle and blood vessels throughout the body. Chronic overuse of nasal decongestants can cause excessive stimulation of the heart leading to palpitations, and blood vessel constriction, causing elevated blood pressure. This side effect is generally observed in orally administered decongestants, while on the other hand topically administered decongestants are believed to be minimally absorbed through the nasal mucosa and, thus, exert practically no significant effect on the cardiovascular system in healthy individuals.⁴

Special Precautions for Nasal Decongestants

There are several conditions that can get exacerbated whenever patients use nasal decongestants. Please, consult with your primary care physician or pharmacist before using nasal decongestants in these conditions. Unmonitored use of nasal decongestants can lead to severe complications.

• Diabetes - like adrenaline, nasal decongestants can cause elevated blood sugar through effects on adrenergic receptors.⁵ Thus, decongestants can cause abnormal glucose peaks and poor glycaemic control in diabetic patients
• Heart disease and stroke - in patients with underlying ischaemic heart disease and/or brain ischaemia, nasal decongestants can lead to blood vessel constriction and further restricted blood flow to the heart and brain, respectively, inducing a heart attack or ischaemic stroke in the process⁶
• Hyperthyroidism - as mentioned above, nasal decongestants can increase the heart’s workload. In people with abnormally high thyroid function, decongestants can exacerbate an underlying heart disease
• Prostate problems - nasal decongestants can cause constriction of the smooth muscle of the prostate in men, restricting normal urine flow from the bladder to the urethra, causing discomfort and increasing the risk of urinary tract infections. Thus, healthcare professionals should be vigilant of decongestant use in male patients over the age of 50 years who are at higher risk of benign prostate hyperplasia and underlying urinary retention⁷

How to Treat Side Effects of Nasal Decongestants

Short-term use of nasal decongestants can bring temporary relief to nasal congestion and sinusitis, but they generally don’t treat the underlying cause, and soon after their effect ends, the symptoms return.

• The risk of developing these side effects can be minimised by using nasal decongestants for a short period of time, no longer than 7 days, while some experts in practice have recommended an even shorter period of only 3 to 5 days.² Decongestant use should be discontinued gradually by reducing the frequency of use day by day to avoid severe rebound congestion
• Saline sprays are generally recommended to help rinse the nasal passages while the decongestant effect wears off. If rhinitis persists despite complete discontinuation and substitution with saline sprays, a healthcare professional may prescribe topical corticosteroids to relieve inflammation
• Patients should drink lots of water and may use air humidifiers and steam inhalations, as well as sucking on lozenges, to avoid the symptoms of nose and throat dryness
• Some people have a deviated nasal septum as a result of nose trauma. A plastic surgeon can repair nasal septum deviation by a procedure known as septoplasty⁸ 
• In case of an underlying bacterial or viral infection, a patient may need to take antibiotics or antivirals to relieve the symptoms, prescribed by a healthcare professional
• Allergies can also cause chronic congestion of the nose and sinuses - allergic rhinitis and allergic sinusitis. In that case, an allergologist can determine the exact cause and suggest lifestyle changes that minimise exposure to the causative allergens. Allergen immunotherapy is a preventive option for allergic reactions in which a person’s immune system is exposed to small doses of allergens that weaken the immune reaction and severity of allergic responses.⁹ Nasal washes with clean tap water or saline can help rinse the nose from pollen and other allergens to prevent the onset of allergic reactions

If nasal congestion or sinusitis persists after 7 days of treatment, please visit your primary care physician or pharmacist to determine the potential underlying cause and choose the right treatment for your condition, or refer you to another specialist.

Summary

While nasal decongestants can provide quick relief for sinusitis symptoms, their overuse carries significant long-term risks. Prolonged use beyond the recommended duration can create a cycle of overuse and further congestion that can worsen the quality of life of affected individuals. As a pharmacist myself, I advise patients to use decongestants cautiously, and adhere to the prescriber’s guidance for safe use.