Sara E. Miller, PharmD Candidate

Decongestants are α-adrenergic agonists (sympathomimetics) that constrict blood vessels in the nasal mucosa to relieve symptoms of nasal obstruction.

Highly vascularized mucosa covers all surfaces within the human nose.

Exposure to allergens, infections, or irritants, causes dense subepithelial blood vessel network distention, leading to congestion, mucosal swelling, nasal airflow obstruction, reduced nasal cavity volume, and vasodilation.

Decongestants are available in oral and topical intranasal formulations, both of which carry serious cardiovascular risks that warrant clinician attention to patient selection and therapy duration.

Practitioners must recognize the risks of prescribing and recommending all medications. Effective patient education is important to prevent adverse events (AEs). The

suggests drug-specific counseling points to raise with patients when recommending a decongestant.

When counseling patients looking for congestion relief, clinicians should determine patient specific risks such as age, comorbidities, concurrent medications, and intended duration.

The FDA warns that children under 2 years should not receive decongestants because of potential life-threatening AEs, including convulsions and rapid heart rates. In 2008, manufacturers voluntarily revised cough and cold products labels to state “do not use” in children under 4 years.

Children and older adults are more likely to experience AEs from oral decongestant use.

The most common AEs, insomnia and irritability, can occur in up to 25% of patients.

AEs are more common with oral decongestants because minimal systemic absorption occurs with topical decongestants. Propellant- and vehicle-associated effects include burning, local dryness, sneezing, stinging, and trauma from the tip of the administration device.

Importantly, topical decongestant use can cause rebound congestion or rhinitis medicamentosa. The exact cause is unknown, but long duration of therapy, preservative agents such as benzalkonium chloride, and short-acting products are suspected as contributing factors.

Most decongestant labels must state, “Do not take this product if you have heart disease, high blood pressure [BP], thyroid disease, diabetes, or difficulty in urination due to enlargement of the prostate gland unless directed by a doctor.”

Systemic decongestants cause generalized peripheral vasoconstriction,

and AEs include arrhythmias, hypertension, palpitations, and tachycardia.

Hypertension is particularly concerning because it affects nearly half of American adults, with many unaware of their condition.

The American Heart Association recommends that patients with high BP consult a health care professional before taking any OTC medications or supplements.

No clear evidence exists that any 1 decongestant is safest in this population.

Results from studies show that pseudoephedrine causes an average increase of 1.2 mm Hg in systolic BP in patients with controlled hypertension. However, it is unclear whether this rise in systolic BP is linked to clinical outcomes.

Higher doses and immediate-release preparations were associated with greater BP increases.

Products intended for patients with high BP (Coricidin HBP) generally do not contain a decongestant. These products usually contain a combination of ingredients that may or may not be appropriate, depending on the patient’s symptoms.

Decongestants can interact with monoamine oxidase inhibitors, tricyclic antidepressants, antihypertensives, indomethacin, β-blockers, methyldopa, and other central nervous system (CNS) stimulants.

Decongestants effectively reduce respiratory tract obstruction but have no effect on other symptoms, including pruritus, rhinorrhea, and sneezing. Thus, practitioners often recommend decongestants combined with other agents, such as antihistamines and mucolytic agents.

When recommending a decongestant, clinicians must be aware of medication interactions, possible drug-induced causes of nasal congestion, and potential duplicate therapies and overdose risk.

Rebound congestion from overuse of topical nasal decongestants is the most commonly recognized type of drug-induced congestion. Other drugs that can cause nasal congestion are aspirin, β-blockers, and nonsteroidal anti-inflammatories.

It is important to adhere to FDA-approved doses because acute overdoses can be life-threatening. Systemic overdoses cause excessive cardiovascular collapse, CNS stimulation, coma, paradoxical CNS depression, and shock. Symptoms of CNS stimulation include anxiety, fear, hallucinations, insomnia, restlessness, and tremors. If any of these symptoms occurs, patients must discontinue therapy.

Advise patients to return if symptoms do not improve within 7 days of oral decongestant therapy or are accompanied by a fever.

Always recommend intranasal decongestants for short durations to prevent rebound congestion.

Remind patients of the importance of self-monitoring BP, especially while taking decongestants. Use open-ended questions to determine how frequently patients monitor their BP, assess their technique, and promote medication adherence.

Clinicians can recommend the lifestyle modifications and nasal products listed in the

Consider the primary symptoms and the underlying etiology of the patient’s condition when selecting pharmacotherapy alternatives or additions to decongestants.

Sara E. Miller is a PharmD candidate at the University of Connecticut School of Pharmacy in Storrs.

Gentile DA, Pleskovic N, Skoner DP, et al. Allergic rhinitis. In: Leung D, ed.

Pediatric Allergy: Principles and Practice.

2nd ed. Philadelphia, PA: Saunders; 2016;210-218.

Corboz MR, Rivelli MA, Mingo GG, et al. Mechanism of decongestant activity of alpha 2-adrenoreceptor agonist.

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Corey JP, Houser SM, Ng BA, et al. Nasal congestion: a review of its etiology, evaluation, and treatment.

The facts about high blood pressure. American Heart Association website. heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure. Accessed November 5, 2018.

Hollander-Rodriguez JC, Monjoy HL, Smedra B, Prouty JP. Clinical inquiry: do oral decongestants have a clinically significant effect on BP in patients with hypertension?

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Articles

Decongestants are Î±-adrenergic agonists (sympathomimetics) that constrict blood vessels in the nasal mucosa to relieve symptoms of nasal obstruction.

Why Decongestants Can Pose a Cardiovascular Risk

Rosacea, an incurable chronic condition, affects more than 16 million Americans and usually presents in adulthood.

Common signs include central facial erythema, flushing, and inflammatory lesions (papules, pustules). Rosacea has inflammatory, neural, and vascular components.

Retail health care practitioners can treat patients with rosacea in these 10 easy steps:

Researchers have not identified rosacea’s underlying cause. Symptom frequency and severity are patient specific and can vary over time. Successful symptom management involves avoiding triggers, using gentle skin care products, and, often, prescription medication.

2. Raise resource and support system awareness.

Most patients with rosacea experience depression, embarrassment, social anxiety, and stress. Emotional stress can trigger outbreaks, creating a cycle detrimental to mental health.

Cognitive behavioral therapy relieves anxiety, a fear of blushing, and stress.

Social support forums and groups also help patients with rosacea manage the psychological effects. Table 1 lists patient-friendly resources.

) is essential to avoid exacerbation. Sun exposure is the most common trigger, so advise patients to wear protective clothing and sunscreen every day.

Long-term topical beta-blockers, corticosteroids, niacin, and vasodilator scan also trigger flare-ups.

Recommend that patients keep a diary or take daily selfies, noting what activities, diet, and exposures contribute to symptom exacerbations. The National Rosacea Society offers a free trigger diary (rosacea.org).

4. Stress behavior modifications, especially sun avoidance.

Sun exposure can worsen rosacea even in those with dark skin, so all patients must wear sunscreen year round. Recommend broad-spectrum sunscreen with a sun protection factor of 30+ and ingredients that reflect ultraviolet rays, such as titanium oxide and zinc oxide.

Patients should avoid physical activities (bike riding, football, horseback riding, etc) that cause facial friction or require headgear. Although they need to remove facial dirt and oil, patients also must limit showering to once or twice daily with lukewarm water and mild cleansers. Immediately after showering, they can apply unscented emollients or oils.

5. Determine the patient’s top treatment priority.

Most topical rosacea treatments are available in various forms (see Figure 2

Ask patients what features they dislike or like to improve adherence. Ask what they have tried in the past, recommending OTC products first and then prescribing if necessary. Undertreatment is common, so do not shy away from prescription products.

7. Offer an everyday facial skin care routine example, such as this one

Cleanse first, massaging with fingertips in a circular motion, and avoid abrasive cloths or tools. Rinse the cleanser off and gently pat dry.

. Apply products with the thin- nest consistency before occlusive ointment-based products.

Refer to package inserts for medication-specific application instructions.

Wait a few minutes until medication completely dries before gently applying moisturizer.

For the greatest barrier protection, apply sunscreen to dry skin.

Use light liquid-based foundation that spreads easily. Avoid difficult-to-spread-and-remove foundations and waterproof makeup.

8. Manage expectations for topical prescriptions.

Select prescription topicals based on patient-specific subtypes and most bothersome symptoms. Azelaic acid and metronidazole address papulopustular lesions. Common adverse effects include burning, itching, skin irritation, and stinging. This regimen takes at least 6 to 8 weeks for a therapeutic response; azelaic acid is slightly more rapid acting.

Advise patients that they will use topical agents for life.

Brimonidine gel lessens persistent bothersome redness between flare-ups within 30 to 60 minutes. Rebound or worsening redness is a potential adverse effect, along with burning, contact dermatitis, and flushing. Assess efficacy in 2 to 4 weeks.

9. Consider oral anti-inflammatory antibiotics

. Patients with moderate to severe rosacea can take an anti-inflammatory dose of modified-release doxycycline in addition to, or instead of, topical therapies. For flare-ups, use doxycycline (40 mg/d) for 10 to 14 days and up to 9 months for maintenance. Reserve oral antibiotic doses of doxycycline (50 to 200 mg/d) for poor responders to low- dose antibiotic and topical regimens.

Inform patients that antibiotics for rosacea will not treat bacterial infections and cannot be used during pregnancy. Doxycycline can cause adverse gastrointestinal effects and sun sensitivity.

10. Step-up treatment for refractory/severe cases.

Isotretinoin is an option for refractory/severe cases, but it is contraindicated during pregnancy and requires frequent lab monitoring.

Some patients may opt for modalities such as laser light treatment, but the cost limits its accessibility.

Inform patients interested in complementary or alternative medicine options about the limited efficacy, and recommend sticking with FDA-approved products.

is a PharmD candidate at the University of Connecticut School of Pharmacy in Storrs.

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Rosacea medical management guidelines. American Acne & Rosacea Society website. acneandrosacea.org/medical-professionals/rosacea-medical-management-guidelines. Accessed June 27, 2018.

Del Rosso JQ, Baum EW. Comprehensive medical management of rosacea: an interim study report and literature review.

Survey shows controlling stress can reduce flare-up frequency. National Rosacea Society website. rosacea.org/rr/2011/fall/article_3.php. Published Fall 2011. Accessed June 27, 2018

Heisig M, Reich A. Psychological aspects of rosacea with a focus on anxiety and depression.

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Coping with rosacea. National Rosacea Society website. rosacea.org/patients/materials/coping/intro.php. Accessed June 27, 2018.

Rosacea diary booklet. National Rosacea Society website. rosacea.org/patients/materials/diary/index.php. Accessed June 27,2018.

6 rosacea skin care tips dermatologists give their patients. American Academy of Dermatology website. aad.org/public/diseases/acne-and-rosacea/rosacea/6-rosacea-skin-care-tips-dermatologists-give-their-patients. Accessed June 27, 2018.

Subramanyan K. Role of mild cleansing in the management of patient skin. Dermatol Ther. 2004;17(suppl 1):26-34.

Wehausen B, Hill DE, Feldmen SR. Most people with psoriasis or rosacea are not being treated: a large population study.

2017;35(2):213-217. doi: 10.1016/j.clindermatol.2016.10.017.

Oracea (doxycycline) [prescribing information]. Fort Worth, TX: Galderma Laboratories LP; 2013. www.accessdata.fda.gov/drugsatfda_docs/label/2013/050805s008lbl.pdf. Accessed July 5, 2018.

Weinkle AP, Doktor V, Emer J. Update on the management of rosacea.

2015;8:159-177. doi: 10.2147/CCID.S58940.

Retail health care practitioners can treat patients with rosacea in 10 easy steps.

Sara E. Miller, PharmD Candidate

Articles

Why Decongestants Can Pose a Cardiovascular Risk

10 Steps to Counseling Patients With Rosacea