Are We Overlooking Nasal Decongestant Abuse? A Perspective

Complaints from sinonasal symptoms, including nasal congestion, may seem relatively benign compared to hypertension or diabetes mellitus. However, the literature has shown that sinonasal symptoms carry significantly higher rates of reduced patients’ quality of life. ¹ Conditions associated with nasal congestion are vast; however, most of the data that have been generated on the burden of congestion comes from studies on allergic rhinitis and rhinosinusitis diseases. ² Given the high prevalence and the enormous socioeconomic and health burden of nasal congestion, several medications have been developed to combat this bothersome symptom, yet it is frequently misdiagnosed and mistreated.

Nasal decongestants (NDs) in the form of imidazoline (e.g., xylometazoline and oxymetazoline) are widely available over-the-counter (OTC) medications and have proved to be the most used class due to the rapid decongestant effects, which are heavily commercialized. Although not fully understood, the chronic use of ND can lead to rhinitis medicamentosa (RM), a condition of rebound congestion that occurs upon withdrawal of NDs. ³ Imidazolines act postsynaptically by binding to alpha 2 receptors, triggering vasoconstriction and decreased blood flow, thereby reducing the volume of nasal turbinates and increasing the potency of nasal passages. ⁴ If used excessively, their desirable or beneficial effect may become detrimental, inducing a rebound swelling and congestion, which may reflect a negative feedback mechanism that reduces the release of norepinephrine. With chronic use and then cessation, the sympathetic nerves in the nasal mucosa may lose their ability to retain vasoconstriction, as suggested by Ramey et al.^3,4 It is safe to say that ND sprays can be habit-forming, creating a vicious cycle of congestion, thus perpetuating patients’ symptoms instead of relieving them.

Through our personal and clinical experience, ND abuse has been substantially more noticeable than before. Increased pharmaceutical promotional advertising through different platforms, including national TV channels, strategic medication placement in pharmacies, and lack of awareness of side effects, are all probable contributing factors to increased abuse. Two local studies have investigated this abuse and concluded the highly prevalent usage of NDs and decreased awareness of side effects among the population.^5,6 Older international retrospective studies estimated the incidence of RM to be 1%-9%. ⁷ These numbers may be underrepresented due to the OTC availability of these medications and almost absent publicity. In comparison, a much recent study conducted among the population of the Netherlands concluded an estimate of 14% while stressing how alarming the high prevalence of RM is. ⁸

Without a doubt, the number of chronic ND users is increasing, necessitating the development of supportive guidelines to encapsulate the well-being of patients using ND chronically. Nevertheless, little is known about patients dealing with this condition. A recent study by Scheire ⁹ concluded that the use of NDs has become indispensable by many chronic users; most were aware of how prolonged usage is disastrous, leading them to hide this behavior from others, including health professionals, to avoid criticism, instating stigma around NDs.

The environment and culture play a central role in how individuals use medications. Therefore, unique preparations for the negative impact that NDs may impose on our community can be useful in minimizing both physical and psychological complications, hence reducing health and socioeconomic burdens on the country. To mitigate the overall adverse effects of NDs, we recommend inaugurating personalized and educational workshops for pharmacists on medication usage and adverse effects, as they are usually the first line of contact for patients while urging the relevant authorities to effectuate regulations to reinforce prescriptions for NDs. The safety and warnings of NDs should be emphasized on the package to help reduce incorrect impressions of the product’s safety. Moreover, a change for the better can be obtained through a sensitization campaign focused on raising awareness and educating the public and stakeholders about ND usage. Finally, global efforts should be undertaken to investigate the prevalence of ND abuse and the incidence of RM. This would provide broader insights that can minimize and cushion the unwavering challenges that NDs may impose on the population.