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HEALTH GUIDE / Prescription Drugs / Decongestants

Decongestants

Pseudoephedrine

About

About decongestants

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

Types and differences of decongestants

There are several different types of decongestants available in several forms, including:


  • Eye drops
  • Tablet
  • Capsule
  • Liquid
  • 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 NameBrand Name(s)

pseudoephedrine

Sudafed

pseudoephedrine with triprolidine

Actifed (decongestant plus antihistamine)

pseudoephedrine with fexofenadine

Allegra-D (decongestant plus antihistamine)

pseudoephedrine with loratadine

Claritin-D (decongestant plus antihistamine)

pseudoephephedrine with guaifenesin

Mucinex-D Extended Release (decongestant plus expectorant)

pseudoephedrine with cetirizine

Zyrtec-D (decongestant plus antihistamine)

oxymetazoline

Afrin

xylometazoline

Otrivin

naphazoline

Allerest, Clear Eyes, Naphcon

tetrahydrozoline

Visine

Some common decongestant/antihistamine combinations include:


Generic NameBrand 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/antihistamine/analgesic combinations include:


Generic NameBrand 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/anticholinergic combinations include:


Generic NameBrand 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

Conditions treated

Decongestants are prescribed to relieve symptoms associated with a variety of conditions, including:


  • Allergic rhinitis (hay fever). Inflammation of the mucous membrane that lines the nose due to 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. Inflammation of the 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 cavity in the face. It often leads to nasal congestion and a runny nose. Decongestants help reduce swelling of the mucous membrane in 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.
  • Bacterial infection. Decongestants may be prescribed to patients with bacterial infections, such as ear infections (bacterial infection of the middle ear and eardrum). Though these conditions require antibiotics to fight infection, symptoms can sometimes be treated with a decongestant before the antibiotics take full effect. Decongestants work as an adjunct, removing the favorable environment for the infection.
  • Viral infections (e.g., cold, 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.

Conditions of concern

Decongestants can cause dangerous interactions with some medications and potentially complicate some health conditions. Patients should not take decongestants (even over-the-counter versions) unless they have consulted their 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 to decongestants or other ephedrine-based products, as well as any other allergies (including other medications, food, pollen, dyes, etc.).
  • 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 decongestants 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 the drugs when possible.
  • Diabetes mellitus. Condition in which the body cannot adequately process glucose (blood sugar) for energy. Decongestants can cause an elevated blood glucose level, further complicating the condition.
  • Enlarged prostate. Condition whereby the prostate grows large enough to press on the urethra and interfere with urination. Decongestants can cause individuals with this condition to have trouble urinating.
  • Glaucoma. A group of diseases that affect the optic nerve, which connects the eye to the brain. The condition causes elevated pressure inside the eye. Decongestants can raise blood pressure, worsening this condition.
  • Raynaud syndrome. A type of peripheral vascular disease 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 (hyperthyroidism) or too little (hypothyroidism) of the hormones used to regulate the body’s metabolism. The use of decongestants can exacerbate these conditions.
  • Kidney disease. The use of decongestants can increase the chance of side effects. Patients with kidney disease may require a different dose.
Side effects

Potential side effects

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
  • Headache
  • 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)
  • Hallucinations
  • Weakness
  • Tremors (shaking or trembling)
  • Seizures
  • 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.

Interactions

Drug or other interactions

Patients should consult their physicians 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 medicines, 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 (often 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 the heart, potentially causing irregularities. Their combined use also increases the chance of side effects developing.
  • Caffeine. Using caffeine with a decongestant can cause some of the 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
  • Insulin
  • 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.

How to use

Pregnancy use issues

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 loss 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 mothers 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 mothers. Women who experience this effect should drink plenty of fluids to compensate and consult their physician if they are concerned their child is not receiving enough milk.


Child use issues

Decongestants can sometimes make children jittery because the drug is closely related to adrenaline. In particular, small children and infants are susceptible to this effect. Most physicians agree that children under the age of 6 months should avoid taking decongestants. Older children should try to take decongestants formulated for kids. To receive the proper dosage, parents should make sure their child’s physician is aware of the child’s age.

With children, physicians will often recommend a nasal spray decongestant rather than an oral decongestant. This is because nasal sprays treat a concentrated area, which reduces the amount of decongestant that is 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

Though 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 side effects when taking this type of drug. For this reason physicians often recommend that users of decongestants – particularly those using pseudoephedrine (a common ingredient in decongestants) – who are over 60 use a short-acting form of the drug to reduce the chance of side effects. Older users should refrain from using a controlled-release or long-acting form of the drug.

Symptoms of medication overdose

Patients exhibiting any of these symptoms should contact their physicians immediately:


  • Extreme tiredness
  • Sweating
  • Dizziness
  • 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 the use of the nasal spray 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.

Questions for your doctor

Patients may wish to ask their doctors the following questions about decongestants:
  1. Are decongestants safe for me to take? What type of decongestant is best for me?
  2. Can you explain to me how decongestants work?
  3. How and when should I take this drug?
  4. How long can I safely use this drug?
  5. How will I know if the drug is working?
  6. What will be the next step if the drug fails to relieve my symptoms?
  7. How will this drug affect my current medical conditions other than allergies?
  8. How will this drug interact with other medications I am currently taking?
  9. What side effects may I develop from taking this drug?
  10. What side effects warrant a call to you?
  11. I am thinking about becoming pregnant. Can I continue to take decongestants when I am pregnant?

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