How to treat rhinitis medicamentosa?

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at LSU (Shreveport) Department of Allergy and Immunology

A 47-year-old Caucasian male was seen by the allergy clinic for allergic rhinitis, non-allergic rhinitis, and rhinitis medicamentosa 4 weeks ago. He had been using Afrin several times a day for three years with gradual increase in nasal congestion and increasingly disturbed sleep and dry mouth. During the last visit, we stopped the Afrin and prescribed a prednisone taper starting at 40 mg po daily and continuing for 15 . He also had evidence of nasal polyposis on both sides and a right nasal polyp. We prescribed Singulair 10 mg po daily and Veramyst one spray in each nostril daily.

Approximately 20 days after the last visit, just after he finished his oral taper of steroids, he called back the clinic because of increased nasal congestion. We added a sinus rinse twice a day to his regimen and he felt a substantial relief. He rates his nasal symptoms as 5 out of 10, down from 8 out of 10 during the last visit (on a 0 to 10 scale). Currently, he is using a nasal spray in the evening and nasal rinse in the evening as well and reports feeling much better.

Past medical history (PMH)

Allergic rhinitis, non-allergic rhinitis, and rhinitis medicamentosa. Nasal polyposis. HTN. He had skin-prick test during the last visit and it was moderately positive to trees, black willow, and marginally positive reaction to weeds, English plantain, and mild reaction to two of the molds.

Medications

Veramyst one spray daily, Singulair 10 mg po daily, Allegra 60 mg po b.i.d., Atacand 4 mg po daily.

Social history

Unremarkable.

Family history

Adopted.

Physical Examination

Vital signs: Stable.
Skin: No rashes.
Ears: Normal. Nose: Pale, boggy turbinates, mucoid discharge, polypoid changes on both sides and a nasal polyp on the right. Throat: Postnasal drip and cobblestoning.
Chest: clear to auscultation bilaterally. Cardiovascular system: Clear S1, S2. Abdomen: Soft, non-tender, non-distended. Extremities: No edema.

What is the most likely diagnosis?

Rhinitis medicamentosa and nasal polyposis.

What tests would you suggest?

Asthma often coincides with allergic rhinitis. A spirometry was done and it was normal.

What treatment would you suggest?

This is a patient with allergic rhinitis, non-allergic rhinitis, rhinitis medicamentosa, and nasal polyps. The combination of intranasal steroids and leukotriene antagonist is indicated, and we decided to continue the same treatment. He still has symptoms of nasal congestion, which is expected with the gradual resolution of his rhinitismedicamentosa. We recommended he should stay off Afrin. He should increase the dose of intranasal steroid to twice a day and also use the nasal rinses b.i.d. He is to follow up with us in three months.

Final diagnosis

Allergic rhinitis, non-allergic rhinitis, and rhinitis medicamentosa. Nasal polyposis.


Afrin - Costco.

References

Rhinitis Medicamentosa. eMedicine Specialties > Allergy and Immunology > Medical Topics, 2006.
Diagnosing Rhinitis: Allergic vs. Nonallergic. AFP, 2006.
Vasomotor Rhinitis. AFP, 2005.
Nasal Sprays Can Bring on Vicious Cycle. NYTimes, 2006.

Pseudoephedrine used in allergic rhinitis improved stuffy nose but decreased sexual activity http://goo.gl/1uLxb

Oxymetazoline for 1 month adds to nasal steroid effect in perennial allergic rhinitis, without development of rhinitis medicamentosa. JACI, 2011.

Published: 03/03/2009
Updated: 02/03/2011