All too often, I see patients suffering from a chronically blocked and stuffy nose, whose problem is being caused in large part by the very medication they are using to treat their symptoms. Nasal decongestant sprays come in many different disguises. While many people have heard of being "addicted to Afrin," they fail to realize the same (or similar) active ingredient hides in many over-the-counter nasal sprays. Brands like Neo-Synephrine, NeilMed, Vicks, Mucinex, Zicam, and so-on. If you read the fine print, they will tell you not to use the medication longer than 3 consecutive days. To make this even more confusing for patients, these sprays are usually placed on the shelf right along side sprays that are safe for longer term use, such as topical steroid sprays like Flonase, Rhinocort, and Nasacort. And even worse - the decongestant sprays are much cheaper than these other sprays, tempting the unsuspecting patient to buy them instead.
The condition I'm referring to is so common it even has a fancy medical name: Rhinitis Medicamentosa. This disorder results not from the immediate effects of the sprays, but from the aftereffect, called rebound congestion. To understand why rebound congestion occurs, one needs to know a little about what causes the normal cycle of congestion and decongestion in the nose. Yes, it is normal for the nose to periodically become congested. This is called the nasal cycle and refers to the cyclical swelling of the nasal lining that occurs on one side of the nose at a time, alternating between the sides. Most of the time in normal circumstances, we don't even notice this occurring. The nasal cycle helps keep the nasal lining moist by temporarily decreasing airflow. It may also help the nasal tissue stay healthy by allowing increased blood flow, with its beneficial oxygen and nutrients.
What causes the rebound congestion seen in rhinitis medicamentosa?
The congestion that occurs during the nasal cycle is controlled by a delicate balance between the two opposing parts of the autonomic nervous system. These two systems, the body's "Yin" and "Yang," are the sympathetic and parasympathetic nervous systems. The balance of these two systems is important throughout the body, having roles in everything from digestion, to blood pressure, to lung function, to sexual performance. In the nose, sympathetic activity causes constriction of the small arteries in the tissue, allowing less blood in and letting more blood out, which results in decreased swelling of the tissue. Parasympathetic activity accomplishes the opposite, dilating the small arteries and leading to increased tissue swelling.
Nasal decongestants work by mimicking the activity of the sympathetic nervous system in the nasal tissues, resulting in decreased congestion of the nasal lining. The longer this is used, the more the nose attempts to balance out the situation by decreasing its natural sympathetic activity and increasing parasympathetic activity. When the effects of the medication wear off, the pendulum swings the other way due to the derangement of the sympathetic-parasympathetic balance, resulting in rebound congestion. In addition, long term use of the spray may actually damage nasal tissues by depriving them of oxygen and nutrients for prolonged periods of time. The damaged tissue then swells even further.
How is rhinitis medicamentosa treated?
To state the obvious, the nasal decongestant spray must be stopped! This is easier said than done, of course. Before trying to do this, it is helpful to figure out why the spray was started in the first place. Sometimes, it was as simple as a viral cold or sinus infection. In these cases, the original problem has actually resolved, so really the only problem to address is the nasal spray itself. In other cases, there may be other ongoing issues that make the situation more difficult, such as a deviated nasal septum, nasal polyps, allergies, or chronic sinusitis. In addition to stopping the decongestant spray, these other problems must also be addressed to provide satisfactory symptom relief.
There are medications that can ease the transition as patients are stopping the decongestant spray. One is a topical nasal steroid spray, such as Flonase or Nasacort. This does not have an immediate effect like the decongestant spray, so using it for several days before weaning down the decongestant spray may be the most successful strategy. For more severe causes, an oral steroid like prednisone in addition to the topical steroid spray may be helpful. '
How do I get myself off the nasal spray?
As far as stopping the decongestant itself, there are 3 strategies to consider:
1) The "cold turkey" method. It will be a rough week or two, but this is the most direct way to a happier nose.
2) The "one side at a time" method. Continue the spray on one side while the other goes through its rebound phase, then stop it altogether when the first side is doing better.
3) The "serial dilution" method. Buy a few bottles of standard saline nasal spray. Take the first bottle and dump 1/2 of the saline out, filling the rest with the decongestant spray. Then take another fresh bottle of saline, dump 1/2 of it out, and fill the rest with the diluted decongestant spray. Do it one more time. Now you have a 1/2 concentration, 1/4 concentration, and 1/8 concentration spray. Wean down 1 week at a time.
Personally, I think the "cold turkey" method is the best, with the help of the other medications I mentioned, but some patients may do better with one of the other strategies.