Decongestant treatments - what are the options and what works best?

Stuffy and runny noses are frustrating hallmarks of the common cold. Nasal sprays that tackle both symptoms simultaneously can provide relief and help people get back to their normal activities.

A bizarre paradox of the common cold is it not only causes congestion but often leads to a runny nose too. These contrasting yet simultaneous symptoms make for a pretty miserable few days.

Patients are left scratching their heads about what will provide relief. This is a conundrum pharmacists are often asked about, particularly during autumn and winter when cold and flu viruses become more of a problem.

The key role of pharmacists

Community pharmacists are more important than ever, as fewer people are seeing their GP face to face during the COVID-19 crisis. Pharmacies should be the first port of call for any minor ailments, including cold and flu. Recommending over-the-counter products can also prevent patients from requesting unnecessary antibiotics, which is vital for curbing the growing problem of antimicrobial resistance.

"Going forward, the pharmacy team's role in actively supporting patients' self-care, giving advice on the management of cold and flu-type symptoms and which medicines might be most appropriate, is going to be key," says Dr Soha Dattani, head of Director of Scientific Affairs at GSK Consumer Healthcare.

Before recommending a combination decongestant and runny nose product, look for any red flags that would require immediate referral to a GP or another healthcare professional. This is particularly important if the patient says they've been experiencing symptoms for longer than a week.

The benefits of dual-action products

Decongestants, in whatever form you choose, are highly effective for providing relief from stuffiness but they won't stop a snotty nose. Happily, products that treat both the infuriating drip drop of mucus and a blocked nose are now available in pharmacies, meaning patients can tackle their tricky symptoms with a single treatment.

GSK's Otrivine Extra Dual Relief is a nasal spray containing active ingredients xylometazoline hydrochloride and ipratropium bromide. It used to only be available on prescription but has recently been approved by the MHRA to become a pharmacy-only product. Xylometazoline hydrochloride is the decongestant and constricts the nasal blood vessels while ipratropium bromide acts on the lining of the nose to reduce the production of mucus.

Dattani says a combination product may improve patient compliance as people don't have to take multiple treatments for all their cold symptoms and risk potentially doubling up on active ingredients.

"It's a single product with a measured dose so it's much easier to use and more convenient for patients," she says. "This could help reduce unnecessary treatment and the risk of any inadvertent overdose that might occur if someone was taking two separate intranasal preparations or tablets."

Topical or systemic - what should I recommend?

For the blocked nose, decongestants can help. They work by constricting nasal blood vessels, which shrinks the mucous membranes, allowing the patient to breathe easily again.

Decongestants are available in both topical and tablet form. The tablets usually contain active ingredients pseudoephedrine or phenylephrine– there are several medical conditions where these are contraindicated, which are outlined below. Decongestants delivered directly into the nose, usually as a spray, often contain ephedrine, oxymetazoline or xylometazoline. Sprays are the fastest-growing type of decongestant.

Some patients will have a preference for one over the other but nasal sprays do provide some advantages over tablets, points out Dattani. "A spray acts locally on the nasal mucosa to clear and provide relief from the congestion and enable patients to breathe more comfortably again. It does this in a faster and more direct way than tablets."

That's because a tablet has to travel through the digestive system before entering the bloodstream to treat the congestion. Dattani says sprays can provide relief up to six times faster than tablets. Nasal sprays are able to work within about five minutes, whereas oral decongestants take around half an hour to have an effect.

Using decongestants safely

As with any treatment, pharmacists should explain clearly to patients how to safely use nasal sprays for the common cold.

For instance, patients should take just one puff (a single metered dose) of Otrivine Extra Dual Relief in each nostril up to three times a day, leaving at least six hours between doses.

When recommending these products, it is important to check for interactions with other medicines. "As with all medicines it's really important that both the pharmacy team and the patient read the instructions very carefully," cautions Dattani.

While nasal decongestant sprays are less likely to cause some of the side effects associated with decongestant tablets, such as high blood pressure and tachycardia, they mustn't be overused. Using decongestants too often can lead to nasal dryness and nosebleeds in some people. Occasionally overuse causes rebound congestion where patients find their stuffiness can actually get worse.

An overview

As the first point of contact for many patients with cold and flu symptoms this winter, pharmacists have access to a range of products they can recommend to manage and minimise symptoms.