A rhinitis medicinalalso known as rebound congestion, is the inflammation of the nasal mucosa caused by the excessive use of topical nasal decongestants.
This type of rhinitis is classified as a subset of drug-induced rhinitis. Generally, nasal decongestants are used for the relief of nasal congestion due to allergic rhinitis, acute or chronic rhinosinusitis, nasal polyps or upper respiratory tract infection.
The first nasal decongestants originated mainly from ephedrine, where there were reports of rebound congestion after prolonged use. This condition has since been observed to develop within 3 days and up to 4 to 6 weeks of use.
The cause of this condition is due to prolonged use of more than 7-10 days.
Physiology of nasal congestion
The vascular system of the nasal mucosa is divided into resistance vessels, which are the arterioles, and capacitance vessels, which are the venous plexuses. These vessels are regulated by specific receptors. Stimulation of these receptors causes a decongestant effect, leading to a decrease in blood flow and, consequently, a decrease in nasal edema and rhinorrhea (runny nose).
There are a number of factors that contribute to nasal congestion, including stimulation of the parasympathetic nervous system, release of local mediators, and stimulation of the release of histamine, tryptase, kinins, prostaglandins, and leukotrienes, inducing a general change in nasal resistance and capacitance of the nasal passages. vases.
Medicinal rhinitis is one of the possible effects of excessive application of nasal decongestants.
Nasal decongestants can be classified as beta-phenylethylamine derivatives or imidazoline derivatives. Beta-phenylethylamine derivatives mimic the effects of sympathetic nervous system stimulation, helping to produce vasoconstriction through activation of certain receptors, which are alpha-1 adrenoreceptors.
Imidazolines, on the other hand, produce their effect mainly through another receptor pathway, the alpha-2 adrenoreceptors. This difference in receptor sensitivity makes imidazoline agents more effective in reducing mucosal blood flow due to their vasoconstrictor effect on both capacitance and resistance vessels in the nasal mucosa.
Decongestants with imidazoline derivatives demonstrate a more potent and longer acting effect. For example, 0.1% xylometazoline hydrochloride, which is an imidazoline derivative, works in a few minutes and lasts up to 10 hours, while 1% phenylephrine works in 15 to 20 minutes, with effects lasting from 2 to 10 hours. 4 hours.
Types of Nasal Decongestants
The main types of nasal decongestants that cause rhinitis medication are those derived from beta-phenylethylamine, including ephedrine and phenylephrine. And the imidazoline derivatives which include naphazoline, oxymetazoline, xylometazoline and benzalkonium chloride.
Benzalkonium chloride, used in nasal decongestant preparations, is associated with the exacerbation of rhinitis due to medication, as it increases the risk of developing this type of rhinitis by inducing swelling of the mucosa.
Rhinitis medication is more common in young and middle-aged adults, with a similar rate in both men and women.
There are reports that the incidence ranges from 1% to 9% in otorhinolaryngology clinics. This can be explained by the availability of nasal decongestants sold in pharmacies without the need for a prescription.
Symptoms of Rhinitis Medication
Patients usually report a recurrence of nasal congestion, particularly without rhinorrhea (runny nose). During the anamnesis, it is common to reveal the prolonged use of some nasal decongestant.
When nasal congestion is severe, it can cause mouth breathing, dry mouth and snoring. During the clinical examination, the physician may observe swelling of the nasal mucosa, an erythematous and granular appearance, in addition to pale and edematous appearances.
As rhinitis medication progresses, the nasal membrane becomes atrophic and crusty.
How is rhinitis medication diagnosed?
The diagnosis of drug-induced rhinitis is clinical. There are no definitive biochemical tests or imaging studies that can confirm this condition. Therefore, it is important for the physician to carry out a careful evaluation of the patient’s symptoms and history in order to formulate an accurate diagnosis.
It is also vital to recognize that other nasosinusal conditions can coexist with rhinitis medication.
Treatment of drug-induced rhinitis
The treatment of drug-induced rhinitis is based on suspending the cause of the problem, which is the nasal decongestant.
Patients should be advised that nasal congestion may temporarily worsen with the discontinuation of the decongestant, so as not to consider that there is a treatment failure. It is important for the patient to understand that stopping abruptly can make symptoms worse. Then, the doctor will instruct the patient to slowly wean off the medications.
When the patient is no longer using nasal decongestants, the doctor will recommend other treatments to relieve nasal congestion, including:
- Glucocorticoid nasal sprays, containing steroids to reduce inflammation. The use of intranasal corticosteroids reduces symptoms of rebound congestion, and this has been proven in animal studies and small human trials;
- Oral decongestants, which are those medicines that the patient takes by mouth to reduce swelling and congestion;
- Saline sprays, which do not contain chemicals in their composition.
How long does it take to recover from rhinitis medication?
It takes approximately one year for a person to fully recover from rhinitis medication in cases of long-term overuse.
The good news is that drug-induced rhinitis is reversible. Most patients no longer have symptoms after reducing the frequency of use of nasal decongestants.
You can reduce your risk of developing rhinitis medication by using nasal decongestants only as directed. Read the package carefully if you are going to use over-the-counter decongestants, paying close attention to how much to use and how often.
Using this type of medication is challenging, as they are often available over the counter.
Consult a doctor if nasal decongestants do not reduce congestion. He may indicate other treatments that do not lead to rhinitis medication.
It is important that patients receive information from their physician about the side effects of excessive use of nasal decongestants before prescribing the medication. Patients should be warned that repeated short-term use of a nasal decongestant, even after one year of discontinuation, can lead to rhinitis medication.