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Symptomatic care options for adults with acute rhinosinusitis

Symptomatic care options for adults with acute rhinosinusitis
Class Selected medication options Advantages Disadvantages
Oral analgesics and antipyretics (preferred)
  • Acetaminophen
  • NSAIDS (eg, ibuprofen, naproxen)
  • Provide systemic pain relief and fever control
  • Generally well-tolerated
  • Acetaminophen use should be limited or avoided in patients with advanced-stage liver disease or decompensated cirrhosis
  • NSAIDs are avoided or used with caution in patients with cardiovascular disease, chronic kidney disease, or advanced-stage liver disease or cirrhosis
  • NSAIDs can be associated with increased risk of bleeding and gastrointestinal upset
Intranasal glucocorticoid sprays (preferred)
  • Fluticasone propionate
  • Mometasone
  • Triamcinolone
  • Relieve congestion by reducing inflammation
  • May be particularly helpful for patients with allergic rhinitis
  • Can cause epistaxis and sore throat
Intranasal saline spray
  • Intranasal sterile saline
  • Moisturizes passages and loosens secretions
  • May temporarily improve nasal passage patency
  • Useful in combination with intranasal glucocorticoid sprays
  • Some patients may find this difficult or uncomfortable
  • Saline must be sterile
Intranasal anticholinergic spray
  • Ipratropium bromide
  • Significantly reduces rhinorrhea
  • May not improve congestion
Intranasal decongestant sprays
  • Oxymetazoline
  • Can improve nasal patency and promote drainage
  • May cause rebound congestion or mucosal damage when used for long-periods
  • Should not be used for >3 days
Oral decongestants
  • Pseudoephedrine
  • Phenylephrine
  • Relieves congestion through vasoconstriction
  • Pseudoephedrine may be more effective than phenylephrine
  • May be particularly helpful for patients with Eustachian tube dysfunction (eg, ear pain, a sensation of ear fullness or pressure, hearing loss, and/or tinnitus)
  • Avoid or use with caution in patients with cardiovascular disease, hypertension, angle-closure glaucoma, or bladder neck obstruction due to sympathomimetic effects
Oral antihistamines
  • First generation:
    • Clemastine
    • Diphendydramine
  • Second generation:
    • Fexofenadine
    • Loratadine
    • Cetirizine
  • First-generation agents can be useful for drying effect
  • Second-generation agents can be useful in patients with allergies
  • Available in combination with oral decongestants
  • Can lead to over-drying, thickened, difficult-to-mobilize secretions, and increased discomfort
  • Can cause drowsiness, cognitive impairment, and anticholinergic effects
Oral expectorants
  • Guaifenesin
  • Can promote drainage by thinning secretions
  • Side effects can include gastrointestinal upset and drowsiness
The approach to symptomatic care for patients with acute rhinosinusitis is typically based on the patient's symptoms, comorbidities, and preferences as well as the potential adverse medication effects. Most medications described above can be obtained over-the-counter in the United States and elsewhere. Other useful supportive measures include mechanical saline irrigation, which is reviewed in a separate UpToDate table. Key risks and benefits are provided in this table. For detailed discussion and comprehensive review of adverse effects as well as drug interactions, refer to the UpToDate text, Lexicomp drug monographs, and drug interactions program.
NSAIDs: nonsteroidal antiinflammatory drugs.
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