Oral Decongestants
Place in Therapy
Place in Therapy
It is well-established that the “common cold” is viral and highly variable in nature and thus is a difficult disease to treat prophylactically, or indeed to truly “cure” with some variety of treatment (1). Thus, care of the patient presenting with the common cold is limited to symptomatic relief while the body eradicates the infection (2). Symptoms of rhinovirus infection are generally localized to the upper respiratory tract, and thus symptomatic relief is best targeted to these areas (1). Common symptoms that present as irritating for the patient are the nasal symptoms, including sneezing, rhinorrhea, and nasal congestion (potentially coupled with sinus pain/headache/etc.) (1). Thus, the application of a decongestant is reasonable in order to decrease the inflammation of the nasal tissues that leads to these symptoms.
Oral decongestants currently on the market include phenylephrine and pseudoepedrine. Pseudoephedrine thus far has shown significant benefit in the short term (within hours of one dose) and significant objective, and notable but non-significant subjective benefits at day 3 of administration (3,4). Phenylephrine has shown conflicting benefit in meta-analyses of a variety of small trials (5,6), and is noted as such in Therapeutic Choices (7). In general, there appears to be a trend towards benefit with phenylephrine as well, although data appears to be non-superior or non-significantly improved (5,6). In a 2011 review of relevant guidelines by the Mayo Clinic, decongestants were given a rating of Ib/D, suggesting that the benefit is extrapolated from level I evidence, and not directly based on the evidence (2). The general consensus is that there is a trend towards benefit, but more studies may need to be done due to the conflicting and low-quality nature of the existing studies. However, Therapeutic Choices indicates decongestants as second-line therapy in the case where topical decongestants are ineffective (7). It is important to note that oral decongestants do not display the rebound congestion associated with prolonged use of topical agents. Thus, oral formulations, due to the conflicting nature of the evidence but trend towards benefit, are second-line for nasal congestion symptoms.
References:
1. Eccles R. Understanding the symptoms of the common cold and influenza. Lancet Infect Dis. 2005; 5(11):718-25.
2. Meltzer EO, Hamilos DL. Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines. Mayo Clin Proc. 2011; 86(5):427-43.
3. Eccles R, Jawad MS, Jawad SS, et al. Efficacy and safety of single and multiple doses of pseudoephedrine in the treatment of nasal congestion associated with common cold. Am J Rhinol. 2005;19(1):25-31.
4. Latte J, Taverner D. Clinical trial of 3 days of treatment with oral pseudoephedrine for the common cold in the southern hemisphere. Am J Rhinol. 2007;21(4):452-5.
5. Hatton RC, Winterstein AG, McKelvey RP, et al. Efficacy and safety of oral phenylephrine: systematic review and meta-analysis. Ann Pharmacother. 2007;41(3):381-90.
6. Kollar C, Schneider H, Waksman J, Krusinska E. Meta-analysis of the efficacy of a single dose of phenylephrine 10 mg compared with placebo in adults with acute nasal congestion due to the common cold. Clin Ther. 2007;29(6):1057-70.
It is well-established that the “common cold” is viral and highly variable in nature and thus is a difficult disease to treat prophylactically, or indeed to truly “cure” with some variety of treatment (1). Thus, care of the patient presenting with the common cold is limited to symptomatic relief while the body eradicates the infection (2). Symptoms of rhinovirus infection are generally localized to the upper respiratory tract, and thus symptomatic relief is best targeted to these areas (1). Common symptoms that present as irritating for the patient are the nasal symptoms, including sneezing, rhinorrhea, and nasal congestion (potentially coupled with sinus pain/headache/etc.) (1). Thus, the application of a decongestant is reasonable in order to decrease the inflammation of the nasal tissues that leads to these symptoms.
Oral decongestants currently on the market include phenylephrine and pseudoepedrine. Pseudoephedrine thus far has shown significant benefit in the short term (within hours of one dose) and significant objective, and notable but non-significant subjective benefits at day 3 of administration (3,4). Phenylephrine has shown conflicting benefit in meta-analyses of a variety of small trials (5,6), and is noted as such in Therapeutic Choices (7). In general, there appears to be a trend towards benefit with phenylephrine as well, although data appears to be non-superior or non-significantly improved (5,6). In a 2011 review of relevant guidelines by the Mayo Clinic, decongestants were given a rating of Ib/D, suggesting that the benefit is extrapolated from level I evidence, and not directly based on the evidence (2). The general consensus is that there is a trend towards benefit, but more studies may need to be done due to the conflicting and low-quality nature of the existing studies. However, Therapeutic Choices indicates decongestants as second-line therapy in the case where topical decongestants are ineffective (7). It is important to note that oral decongestants do not display the rebound congestion associated with prolonged use of topical agents. Thus, oral formulations, due to the conflicting nature of the evidence but trend towards benefit, are second-line for nasal congestion symptoms.
References:
1. Eccles R. Understanding the symptoms of the common cold and influenza. Lancet Infect Dis. 2005; 5(11):718-25.
2. Meltzer EO, Hamilos DL. Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines. Mayo Clin Proc. 2011; 86(5):427-43.
3. Eccles R, Jawad MS, Jawad SS, et al. Efficacy and safety of single and multiple doses of pseudoephedrine in the treatment of nasal congestion associated with common cold. Am J Rhinol. 2005;19(1):25-31.
4. Latte J, Taverner D. Clinical trial of 3 days of treatment with oral pseudoephedrine for the common cold in the southern hemisphere. Am J Rhinol. 2007;21(4):452-5.
5. Hatton RC, Winterstein AG, McKelvey RP, et al. Efficacy and safety of oral phenylephrine: systematic review and meta-analysis. Ann Pharmacother. 2007;41(3):381-90.
6. Kollar C, Schneider H, Waksman J, Krusinska E. Meta-analysis of the efficacy of a single dose of phenylephrine 10 mg compared with placebo in adults with acute nasal congestion due to the common cold. Clin Ther. 2007;29(6):1057-70.