Rhinitis Medicamentosa

Symptoms

Rhinitis medicamentosa manifests as a stuffy nose with swollen and histologically altered nasal mucosa.

Causes

It is the result of prolonged use of decongestant nasal medications (sprays, drops, oils, gels) containing active ingredients such as xylometazoline, oxymetazoline, naphazoline, or phenylephrine. Because the nasal mucosa no longer swells on its own and habituation occurs, the nasal medications are applied again and again. This leads to a vicious circle and dependence. This is preceded by a respiratory disease that has been treated with nasal medication, for example a cold, hay fever, nasal polyps, sinusitis or tubal catarrh. It is not known exactly when the adverse effect begins. According to studies, it begins after 3 or only after 10 days and continues to worsen within a month. The sympathomimetics contained in the nasal medications are responsible, which lead to vasoconstriction in the mucosa by stimulating α-receptors. There are several hypotheses regarding the etiology of rhinitis medicamentosa:

  • Sympathomimetics also stimulate β-receptors, which induce vasodilatation. This is initially masked by the more potent vasoconstrictor effect. However, as the stimulation of β-receptors lasts longer, a rebound with nasal congestion results.
  • A feedback mechanism results in depletion of presynaptic noradrenaline, which is no longer available for vasoconstriction after discontinuation of the agents.
  • Sensitivity of α-adrenergic receptors is decreased by prolonged stimulation, leading to tolerance that promotes excessive use of the agents.

The preservative benzalkonium chloride may also potentially promote the development.

Complications

The stuffy nose can cause discomfort such as snoring, sleep disturbances, dry mouth and sore throat (breathing through the mouth!). In addition, the mucous membrane is damaged and the physiological functions of the nose are disturbed, which promotes the development of acute or chronic respiratory diseases. The development of psychological dependence and withdrawal symptoms such as restlessness and anxiety have also been reported. Nosebleeds may also occur.

Risk factors

Rhinitis is more common in people who are young or middle-aged. It is also common in pregnant women, because pregnancy rhinitis may occur during pregnancy with a stuffy nose that is treated with nasal decongestants. Respiratory diseases predispose to rhinitis medicamentosa (see above).

Diagnosis

The diagnosis is made on the basis of the patient’s history. The clinical signs are not specific and may be caused by other causes. It is possible that another nasal or respiratory condition is present at the same time.

Prevention

Decongestants for the nose should be used cautiously for a maximum of 5-7 days. The dosage specified in the package insert should not be exceeded, and preparations without preservatives should be preferred. Many manufacturers now offer such medications. For the treatment of allergic rhinitis such as hay fever, antiallergic drugs such as antihistamines or nasal glucocorticoids should be used rather than decongestants (!) The same applies to nasal polyps treated with nasal glucocorticoids.

Treatment

According to the literature, “cold turkey” rather than continuous tapering is considered the treatment of choice. The nasal medication is discontinued and subsequently uncomfortable swelling of the nasal mucosa occurs. This can be treated with glucocorticoid nasal sprays such as budesonide, fluticasone or beclometasone for a few weeks. Studies have confirmed that they are effective against nasal oedema, inflammation and congestion. It should be taken into account that the full effect is delayed. Oral glucocorticoids such as prednisone are available as a possible alternative or adjunct. Antihistamines, mast cell stabilizers, oral sympathomimetics, sedatives, and other drugs are also mentioned in some publications as remedies for nasal congestion, but are considered less effective. Seawater sprays and rinses may also relieve symptoms (see also Humidifying Nasal Sprays).As a non-drug measure, elevating the head of the bed may be recommended, as discomfort worsens when lying down.

Things to know

The so-called privinism was already described by Feinberg and Friedlaender in 1945. It is a rhinitis medicamentosa triggered by Privin (= naphazoline). Naphazoline is still on the market. Also referred to as rhinitis medicamentosa or drug-induced rhinitis is nasal congestion or rhinitis triggered by drugs such as NSAIDs, phosphodiesterase-5 inhibitors, estrogens, oral contraceptives, antihypertensives, neuroleptics, or cocaine. This is an adverse effect that usually occurs immediately.