Which decongestant when?

I wanted to discuss decongestant use and some of the myths and misperceptions around what is commonly out there.

A lot of people come in and say, “Well, I tried an over-the-counter remedy,” and they say it didn't help. One thing that I've noticed is that anything containing phenylephrine does not get good patient reviews as a decongestant. Pseudoephedrine, which is, depending on what state you practice in, much more difficult to get, has been shown to be much more effective. So whenever anyone tells me what they're taking, I always ask, “Did you have to go up and ask the pharmacist for it? Or did you just pull it off the shelf?” And if they say they just pulled off the shelf, I know there's still a chance for success and tell them to ask the pharmacist for pseudoephedrine, kept behind the counter.

When you start digging into how these things work and any evidence behind them, it's pretty clear why you would choose one instead of the other. When they started passing more regulations to cut down on methamphetamine creation in the United States, you started seeing pseudoephedrine fall out of use, and almost simultaneously this switchover to incorporating phenylephrine in all the over-the-counter cough and cold medicines as a decongestant. But there have been a number of articles over the years pointing out that it's never really been shown to be effective as a decongestant. One more recent study in 2009 found that pseudoephedrine was much more effective than either phenylephrine or placebo, which were roughly equivalent. Phenylephrine is extensively metabolized whereas pseudoephedrine is not, so you're just not getting as much of the drug going to where it needs to be to deliver the desired effect.

Another myth is around oxymetazoline, for which the idea was, and probably still is, never use it for more than three days, or it can cause this horrible rebound congestion called rhinitis medicamentosa. You have to go way back into, I think, the 1970s and 1980s to find when they were looking to see whether this causes any rebound congestion. In limited small studies on healthy people, there was a little rebound when the medicine wore off, they had congestion, but it didn't keep them from responding to it. Looking at a couple of studies in the 2000s, one showed that people using oxymetazoline three times a day for four weeks had no change in either symptoms or in airflow through their nose. Some people did have a little bit of rebound congestion after two weeks of using oxymetazoline, but three days of a nasal steroid spray, and it was gone. So it's either something that is there in a limited amount for some people that is reversible with a steroid spray, or something that's not there at all. It is a very effective medication. It can give people a lot of benefit. You sleep better, you feel better, you have less nasal drainage. It's another area where we are maybe overly cautious and haven't really had the impetus to get a message out saying, “This is what we know now that the public should be more aware of.”