Nasal Sprays: A General Explanation of the Various Types

If I had a nickel for every patient that uses a nasal spray but cannot recall the name, I’d be a gazillionaire.  “You know, doc,” is a common reply, “the spray they have at the store for noses.”  Thus, the reason for Thomas Jefferson—the guy on our 5 cent piece—in the title picture.

In the world of nasal sprays, there are lots to choose, perhaps too many.  What once was available by prescription only are now over-the-counter (OTC).  Scan the medicinal aisle in a store and you’ll probably scratch your head, musing, “Hmm…what to use, what to use…”  So what should you use?  Below is a short synopsis of the different sprays and their reasons for being.

But first, let’s talk about symptoms, in other words, the specific conditions or sensations that one is experiencing. 

Nasal congestion:  This is a rather vague term used differently by different folks, ranging from a sense of fullness or pressure in the nose or face to a sense of nasal stuffiness or plugging.  A few patients I’ve seen used “congestion” to describe a “fogginess” in the head, with an inability to concentrate.  It’s important to drill down what the patient means by this term.  Most ENTs define congestion as impaired breathing through nose, a result of swollen (congested) soft tissue inside the nasal passages.

Rhinorrhea is nasal drainage, namely a “runny” or dripping nose.  The type of rhinorrhea can vary from loose and watery, to thick and discolored (i.e., yellow, brown, green, bloody or a combination of each). 

Postnasal drainage is similar to rhinorrhea, although in the other direction.  The back of the nose communicates freely with the throat, and thus nasal drainage can run backwards and down the throat.  This often causes throat clearing, throat irritation or itching or cough. 

Nasal pruritis is the fancy medical term for “nasal itching.”  This also can lead to sneezing—a means for the nose to blow out unwanted allergens or irritants.

Sinus pressure, pain, headaches are exactly what they mean, and often we most dive further into a patient’s history to have them more specifically describe the location of quality of such symptoms since they often are quite vague.  The sinuses are airspaces in the skull that drain into the nose.  Blockage of these openings can lead to sinus headaches or facial pain.

Let’s get down and dirty to the different types of nasal sprays out there.  But, as always, some words of caution:

Note: this is not an exhausted discussion of nasal sprays and their side-effects, risks, drug interactions and so forth.  Naturally, you should discuss these issues with your doctor, check product information, particularly if you have other medical problems or taking other medications from chronic health problems.

Nasal decongestant sprays shrink the mucosa by a process of vasoconstriction.  Vaso=vessel and constriction = narrowing or shrinking the diameter of the vessel.  Hence, the blood vessels that supply the nasal tissue are narrowed to reduce blood flow to the target tissues.  These sprays are meant for very short-term use only, for instance, to relieve nasal congestion from a cold or allergy flare-up.  These also can prevent a sinus-related headaches or onset of a sinus infection by improving ventilation to and from the sinuses.  If noticing facial pressure with nasal congestion, using these sprays may be helpful to alleviate both.  They have a quick onset of action, typically within minutes.  Also, for those who have nasal congestion and/or ear pain when flying, these sprays can be helpful when used prior to onset of the flight (especially with descent and landing of the aircraft).

The generic names of these OTC decongestant sprays are oxymetazoline and phenylephrine.   The common brand names are Afrin® and Neo-synephrine®, respectively.  However, there are a variety of OTC sprays with different names that contain these ingredients, so in purchasing these, carefully review the fine print under Active Ingredients.

BEWARE!!!:  These sprays are meant for short-term use only.  Use them for no more than three days in a row.  Otherwise, they can lead to rhinitis medicamentosa, a dastardly condition also known as rebound congestion, where the nasal tissues no longer respond as well to the nasal decongestant spray, becoming congested shortly after the vasoconstriction wears off.  Often the congestion from rhinitis medicamentosa is worse than the initial congestion which prompted the use of the spray in the first place.  So again, be careful, short-term use only.

SIDE NOTE:  Cocaine does the same thing along with anesthetizing the nasal tissues.  Of course, cocaine is not available OTC, it’s addicting, has potentially bad side effects, and in its purest form it’s extremely expensive since it’s, well…illegal.  I mention it here since we often use cocaine (legally, but in a dilute 4% solution) for nasal and sinus surgery.  Its vasoconstrictive properties reduce intraoperative bleeding and can help with postoperative pain.

Nasal steroid sprays reduce the inflammatory response caused by allergens or irritants.  The spray in turn reduces swelling of the mucosa that leads to nasal congestion, drainage and itching.  I’ve listed two of the more common ones with their directions for use:

Fluticasone  (brands are Flonase®, Allerflo® (Kirkland-Costco): 
Ages 4-11 years old:  1 spray each nostril once a day
                Ages 12 years and older:  2 sprays each nostril once a day

Triamcinolone (brand is Nasacort®):  
Ages 2-11 years old:  1 spray each nostril once a day
                Ages 12 years and older:  2 sprays each nostril once a day

Contrary to what many people believe, nasal steroids do not have quick onset of action like the nasal decongestant sprays.  You must use these sprays for at least two weeks consecutively; they will not work right away.  Start these sprays two weeks prior to your peak season when you tend to have problems.  Afterwards, if you are noticing improvement, go ahead and decrease to one spray a day.  If this still keeps the nose open, then try using it every other day.  In children, consider decreasing to one spray every other day after two weeks, and if symptoms remain improved, then every 2-3 days.

Chromium sodium (NasalCrom®) spray is also used for allergies, but is more of a preventative spray.  It works by stabilizing mast cells, which are part of the immune system.  When activated by allergens (protein molecules that trigger an allergic response) the mast cells release histamine.  Histamine then binds to histamine receptors (specifically, H1 receptors) in the body, causing not-so-pleasant things such as edema (swelling), vasodilation (widening of blood vessels), increased blood vessel permeability (which causes serum or fluid to leak into tissues) and smooth muscle contraction (which can constrict the bronchial tubes in the lungs—the cause of wheezing in asthma).  Chromium sodium binds to mast cells and prevents them from releasing histamine.

Antihistamines block the H1 receptors mentioned above.  Thus, if mast cells release histamine, the histamine molecules cannot bind to the receptors and cause those nasty things mentioned above.  Antihistamines are available in oral form (i.e, loratadine, fexofenadine, cetirizine, and diphenhydramine) but these must circulate through your blood to get to the targets.  Antihistamine sprays work directly in the nose with little to no absorption into the blood stream.  The most common antihistamine spray is:

Azelastine (Astelin® or Astepro®):
Ages 6-11 years old:  1 spray each nostril twice a day as needed for rhinorrhea, congestion, postnasal drainage.
Ages 12 years and older: 1-2 sprays each nostril 1-2 times a day as needed

Azelastine helps much more with rhinorrhea, more so than the nasal steroids.  To this date, azelastine is prescription only however.  Azelastine is also indicated for the treatment of vasomotor rhinitis (which we’ll discuss shortly).

Synergistic combination of nasal sprays:
Sometimes a nasal steroid with a nasal antihistamine are used together.  There seems to be a synergistic action when using them together; in other words, the effect of the combination is greater than the sum of its parts.

Azelastine and nasal steroid spray (i.e., fluticasone or triamcinolone): 1 spray of Azelastine in each nostril, followed by one spray of your nasal steroid into each nostril, 2 times a day.

Dymista® is a combination of azelastine and fluticasone.  In my past experience, the cost of this medication was rather high (despite it being a mix of two generic sprays).  Every time I prescribed this, it invariably was denied by the patient’s insurance.  To simplify matters and avoid the frustration and hair-pulling time-waste trying to get pre-authorization (which often was unsuccessful), I simply use the two sprays as above. 

There is a phenomenon called vasomotor rhinitis (VMR) which often hits people who are older, though I’ve seen it in younger people.  I sometimes suffer from this as well (though I don’t consider myself old, but that may be just a personal misconception).  VMR causes a clear, watery rhinorrhea, which is not triggered by allergens or pathogens such as viruses.  Oftentimes it occurs when eating—the nose runs as a person salivates when eating.  Sometimes a change in weather, or going from one room to another with a different temperature may trigger this.  I’ve experienced this during exercise or running at times.  Often there is no trigger at all, and the nose just spontaneously runs and drips for now rhyme or reason.

The cause for VMR is believed to be simulation of the parasympathetic nerves in the nasal mucosa.  These nerves are responsible for dilating blood vessels and increasing secretions from the mucosa—thus the “runny nose” with this condition.  Parasympathetic nerves also stimulate saliva production when eating, which is the reason many folks with VMR have a runny nose during meal time, often carrying Kleenex or tissues to the dining table.  One treatment is a spray that prevents release of acetylcholine (a neurotransmitter) from parasympathetic nerves.  This anticholinergic spray is called ipratropium bromide, which was adapted from the oral inhaler of the same name used as a bronchodilator (to open up the bronchial tubes in the lung).

Ipratropium bromide (Atrovent®): comes in 0.03% for longer term use, and a stronger 0.06% for shorter term use (ie, for common cold symptoms). 
Directions: 1-2 sprays up to three times a day as needed for runny nose.

IMPORTANT NOTE:  I’ve mentioned this before in Nasal Sprays: Proper Technique, but I’ll mention it again.  To best deliver the medications to the nose, use the opposite hand to spray the opposite nose (i.e., right hand for the left nose, left hand for the right). Some of the side effects of the nasal sprays include nasal dryness, nose bleeds, sore throat, headaches.  To prevent these, use nasal saline.  Which then leads to our next type of nasal spray:

Nasal saline (ie, different brands are Ocean®, Ayr®, Neil Med® bottle, Neti Pot®) is a mild salt solution, and basically is a natural product that is similar to what your nose normally produces.  Use 1-2 sprays each nostril 3 or more times a day to rinse and moisturize the nasal passages.  You can also irrigate the nose, but don’t feel you must do this so vigorously such that the solution comes out the other side.  If it does and you can tolerate it, so be it, but don’t force it too much if it doesn’t.  You can gently irrigate or spray, and if it comes out the same side of the nose, that’s OK.  These all can be purchased OTC.

Nasal gel (ie, Ocean®, Ayr®) is a water-based gelatinous product that keeps the nose moist for a longer period of time.  Apply a pea-size amount 2-3 times a day to nose on both sides with clean finger or qtip.  This too is OTC.

These are natural plant oils that can help to moisten and soothe dry nasal passages.  Some people of a condition called atrophic rhinitis, which is a very dry nose, one that creates firm crusts and thick mucous, which in turn causes nasal irritation, pain, blockage and bleeding.  This condition can be a result of the side effects of certain medications, prior nasal surgery (esp. when too much normal tissue is removed, resulting in turbulent nasal airflow) and often unknown causes. 

Ponaris® is an example of a nasal emollient.  It comes in a bottle with a dropper.   Though and OTC product, you may need to ask the pharmacist if it is behind the counter since often this is not on display with the other nasal sprays, or it may need to be special ordered or obtained online.  Ponaris can be used 1-3 times a day, as needed, using as few drops as possible each time.  One should use nasal saline first to rinse or irrigate any crusting out of the nose and the apply the emollient. 

That’s a brief summary of the wonderful world of nasal sprays.  Sniff, breathe and enjoy.

Randall S. Fong, M.D.