eMedicine Specialties > Allergy and Immunology > Medical Topics

Rhinitis Medicamentosa: Treatment & Medication

Author: Natalya M Kushnir, MD, Allergist-Immunologist, Group Private Practice, Allergy and Asthma Medical Group of the Bay Area, Berkeley; Clinical Investigator, Allergy and Asthma Clinical Research Inc, Walnut Creek, California
Contributor Information and Disclosures

Updated: Oct 13, 2009

Treatment

Medical Care

Once rhinitis medicamentosa is identified, topical decongestant use must be discouraged and discontinued as soon as possible. Patients need to be educated on their condition and offered other methods of treatment that will help them with the medical conditions that originally triggered the decongestant use. For those patients unable or unwilling to immediately stop, several methods may ease the withdrawal process.

The first week is often the most difficult for weaning or withdrawal. Several studies confirm efficacy of nasal corticosteroids in the treatment and prevention of rhinitis medicamentosa. Patients can be offered introduction of nasal corticosteroids while being weaned off decongestants. Oral steroids may be necessary. Buffered or concentrated salt solutions can be also offered with nasal irrigation devices such as NeilMed to provide moisturizing and nonaddicting decongestant relief.

Nasal decongestants can be weaned gradually, allowing patients to use sprays at night in one nostril only and alternating the left and right nostril until congestion is decreased.

Pain relief should be provided to patients who don't have ASA sensitivity but are experiencing headache.

Patients should be offered frequent office visits in the first few weeks of treatment to encourage withdrawal and provide emotional support.

Systemic decongestants: These are particularly helpful in patients who began using vasoconstrictive nasal medications to help with allergic rhinitis. As the symptoms associated with allergic rhinitis are relieved, the intranasal medication can be discontinued.

Oral corticosteroids: Although not always necessary, short-course oral corticosteroids, as described below, are the most effective way to break the cyclic use of topical vasoconstrictors. The oral corticosteroids are often used for 5-10 days, with nasal corticosteroids started at the same time and continued until the process is corrected.

Surgical Care

Surgical treatment is not recommended unless polyps or deviated septum are present. Reduction of nasal turbinates is not indicated; if performed, this reduction results in short-lived effect with return of congestion if nasal decongestants are not discontinued. With discontinuation of decongestants, the condition is usually self-resolving.

Consultations

Consult an allergist or otorhinolaryngologist if a patient's case is complicated and refractory to treatment or if the primary care physician is unsure of diagnosis.

Medication

Nasal corticosteroids, systemic decongestants, or oral corticosteroids may ease withdrawal of the offending medication in patients who are unable to stop using nasal vasoconstrictive medications.

Nasal corticosteroids help reduce local inflammation without systemic effect, possibly by reducing nasal congestion sooner. Oral corticosteroids are rarely necessary but are suggested in the adult literature (eg, prednisone 20-40 mg/d for an average-weight adult, tapering over 7-10 d).

Several different nasal steroids are available, including budesonide, ciclesonide, fluticasone propionate, fluticasone furoate, mometasone, beclomethasone, flunisolide, and triamcinolone. These products differ in their delivery vehicles, but they all offer an aqueous delivery system. Although all are equally effective at equipotent doses, they differ in their potency and half-life, which accounts for the difference in dosing frequency (ie, qd vs tid) and the total amount of sprays per dose (ie, 1-2 sprays vs 3-4 sprays).

Corticosteroids

Elicit anti-inflammatory and immunosuppressive properties, and they cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.


Budesonide (Rhinocort, Rhinocort AQ)

Alters level of inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing production of cytokines and other mediators involved.

This product may help patients through the difficult first week by reducing inflammation. Methods are uncertain for treating rhinitis medicamentosa in children. Drug safety is the same as when used for allergic rhinitis. Titrate dose to the least amount needed.

Adult

2 sprays (32 mcg/spray) per nostril bid or 4 sprays per nostril qd

Pediatric

<6 years: Not established
>6-11 years: 1 spray (32 mcg/spray)/nostril qd; may increase to 2 sprays/nostril qd if necessary
>11 years: Administer as in adults

Concomitant use with PO or PO inhaled corticosteroids can enhance the toxicities of corticosteroids

Documented hypersensitivity; infections of nasal mucosa; wound in nasal tract; tuberculosis of the respiratory tract

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Rare cases of nasal septal perforation; common adverse effects include nasal stinging, throat irritation, nasal dryness, epistaxis, and headache


Fluticasone (Flonase)

Has extremely potent vasoconstrictive and anti-inflammatory activity. Has a weak hypothalamic-pituitary-adrenocortical axis inhibitory potency when applied topically.

This product may help the patient through the difficult first week by reducing inflammation. Titrate dose to the least amount needed. Contains 50 mcg per actuation.

Adult

2 sprays (50 mcg/spray) per nostril qd

Pediatric

<4 years: Not established
>4 years: 1-2 sprays per nostril qd; once controlled, maintain at lowest dose possible (ie, 1 spray per nostril qd)

Concomitant use with PO or PO inhaled steroids can enhance the toxicities of corticosteroids

Documented hypersensitivity; infections of nasal mucosa; wound in nasal tract; tuberculosis of the respiratory tract

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Rare cases of nasal septal perforation; common adverse effects include nasal stinging, throat irritation, nasal dryness, epistaxis, and headache

Decongestants

These drugs may be helpful in patients with a component of allergic or seasonal rhinitis as an underlying cause of their rhinitis medicamentosa. They stimulate alpha-adrenergic receptors of vascular smooth muscle. This leads to constriction of dilated arterioles within the nasal mucosa and reduced blood flow to the engorged area.


Pseudoephedrine (Sudafed)

One of many systemic decongestants that may be used.

Stimulates vasoconstriction by directly activating alpha-adrenergic receptors of the respiratory mucosa. Induces bronchial relaxation and increases heart rate and contractility by stimulating beta-adrenergic receptors.

Adult

60 mg PO q4-6h or 120 mg SR PO q12h; not to exceed 240 mg/d

Pediatric

<2 years: 4 mg/kg/d PO divided q6h
2-6 years: 15 mg PO q6h; not to exceed 60 mg/d
6-12 years: 30 mg PO q6h; not to exceed 120 mg/d
>12 years: Administer as in adults

Propranolol, MAOIs, and other sympathomimetic agents may increase toxicity of pseudoephedrine; methyldopa and reserpine may reduce effects of pseudoephedrine

Documented hypersensitivity; severe anemia; postural hypertension or hypotension; closed-angle glaucoma; head trauma; cerebral hemorrhage

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease, diabetes mellitus, prostatic hypertrophy, and increased intraocular pressure

More on Rhinitis Medicamentosa

Overview: Rhinitis Medicamentosa
Differential Diagnoses & Workup: Rhinitis Medicamentosa
Treatment & Medication: Rhinitis Medicamentosa
Follow-up: Rhinitis Medicamentosa
References
Further Reading
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Keywords

rhinitis medicamentosa, rebound rhinitis, chemical rhinitis, drug-induced rhinitis, vasoconstrictor overuse, decongestant overuse, overuse of intranasal vasoconstrictive medications, topical nasal decongestants, rebound swelling, overuse of nasal spray

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Contributor Information and Disclosures

Author

Natalya M Kushnir, MD, Allergist-Immunologist, Group Private Practice, Allergy and Asthma Medical Group of the Bay Area, Berkeley; Clinical Investigator, Allergy and Asthma Clinical Research Inc, Walnut Creek, California
Disclosure: MEDA Honoraria Speaking and teaching; GSK Honoraria Speaking and teaching; MERCK Honoraria Speaking and teaching

Medical Editor

William F Schoenwetter, MD, Consultant in Allergic Diseases, Brainerd Medical Center, Brainerd, Minnesota
William F Schoenwetter, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Physicians, American Medical Association, Joint Council of Allergy, Asthma and Immunology, and Minnesota Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

John E McClay, MD, Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical School
John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting

Chief Editor

Michael A Kaliner, MD, Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy
Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians
Disclosure: Abbott Consulting fee Consulting; Alcon Consulting fee Consulting; Glaxo Consulting fee Consulting; Greer Consulting fee Consulting; Sanofi Consulting fee Consulting; Schering Consulting fee Consulting; Teva  Consulting; Meda Honoraria Speaking and teaching

 
 
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