No doubt about it, the multitude of over-the-counter and prescription medications available to treat nasal and sinus symptoms can be intimidating.

With similar-sounding names and literally hundreds of drug combinations to choose from, it’s a cruel irony that you usually end up having to navigate this maze of medications when you feel least up to it.

The good news is that once you’re familiar with the major drug categories, finding the right product for your symptoms is less confusing than it initially seems.

I should point out that none of the drugs I’m about to discuss are specifically intended to treat chronic sinusitis. Rather, most are approved to treat symptoms of colds and allergies.

But because sinusitis sufferers often have similar symptoms, such as congestion and a runny nose, these drugs can be helpful if you have sinusitis. There are five major categories of drugs relevant to nasal symptoms: decongestants, mucus-thinning agents, antihistamines, pain relievers, and cough suppressants.

Table below includes key information on drugs in the first three categories. Once we’ve looked at each individual drug category, we’ll talk about combination medications.

Cold and Allergy Medications That May Also Be Used for Sinusitis

If You Have . .	. . . Consider Taking	Brands Available*	Active Ingredient	Most Common Side Effects/ Warnings
Congestion	Decongestants	Sudafed	Pseudoephedrine	May raise blood pressure or cause heart palpitations, jitteriness, or insomnia
Thick mucus, postnasal drip	Mucus-thinning agents	Mucinex, Humibid LA**	Guaifenesin	Uncommon
Allergy symptoms, such as drainage, itchy eyes and nose, and sneezing	Sedating antihistamines	Benadryl	Diphenhydramine	Drowsiness, dry mouth
		Chlor-Trimeton	Chlorpheniramine
		Dimetane	Brompheniramine
		Tavist	Clemastine
	Nonsedating antihistamines	Alavert	Loratadine	Uncommon
		Allegra**	Fexofenadine
		Clarinex**	Desloratadine
		Claritin	Loratadine
	Other	Zyrtec**	Cetirizine	Occasional drowsiness

* Generic forms of nonprescription brands also available.
** Available by prescription only.

Decongestants

Decongestant medications are available in both spray and pill form. Spray decongestants such as Afrin, Dristan, Vicks, and Neo-Synephrine contain either oxymetazoline or phenylephrine.

Although these sprays provide rapid relief of nasal congestion. I do not recommend them for people with chronic sinusitis because they offer a high potential for nasal rebound if used for more than three days.

Once you eliminate sprays, you’re left with just one over-thecounter decongestant that comes in oral form: pseudoephedrine, the little red pill commonly sold under the brand name Sudafed.

It is also available in a variety of generic brands. (Another decongestant, phenylpropanolamine, or PPA, was taken off the market in 2000 because of FDA concerns that it increased the risk of stroke.)

Pseudoephedrine acts by constricting blood vessels, thereby reducing blood flow through mucous membranes in your nose. These membranes shrink, leaving more room in your sinus and nasal passages for air to flow and mucus to drain. So if you’re plugged up, taking a decongestant can enable you to breathe again.

It can also relieve a sense of facial fullness and congestion. However, pseudoephedrine has a number of drawbacks. First, it can raise blood pressure, so it’s not recommended for people with hypertension.

Those taking blood pressure medication should check with their doctor before starting to use it. Next, pseudoephedrine is a stimulant, so it can make you feel jittery, hyperactive, or anxious.

In a small number of people, it can even cause heart palpitations (rapid or extra heartbeats). If this occurs, you should discontinue its use. Pseudoephedrine’s stimulant effect can also cause insomnia.

If you experience this side effect but find that pseudoephedrine helps control your symptoms, you may wish to take it in the morning and skip the evening dose.

Mucus-Thinning Agents

Just as pseudoephedrine is the only available oral decongestant, there is just one mucus-thinning agent: guaifenesin. We don’t know exactly how it works, but guaifenesin takes thick mucus and makes it more watery, so it’s easier to clear from your nose and sinuses.

Guaifenesin is also referred to as an expectorant, because it helps people cough up and spit out thick secretions that may collect in the throat or chest. As long as you take the proper dosage, guaifenesin does not normally have side effects.

But there is one critical thing to remember: make sure you’re well hydrated when you take it. Your body must have enough water available to achieve the medication’s mucus-thinning benefit. It’s a good idea to drink an eight-ounce glass of water with each dose.

Antihistamines

A general consensus exists among physicians that oral decongestants and mucus-thinning agents benefit many patients with sinusitis. By contrast, the role of antihistamines is more controversial.

Because antihistamines can dry out your nasal passages and thicken secretions, some doctors believe people with sinusitis should never take them. I don’t share this view.

I believe antihistamines do have a role for many people with sinusitis, particularly those whose infections seem to be related to allergies. And even if you don’t have a history of environmental allergies, a trial of antihistamines should be considered if pseudoephedrine and guaifenesin haven’t provided relief.

Antihistamines act by blocking the release of histamine, a chemical produced by the body in reaction to foreign substances known as allergens.

Histamine release triggers a cascade of inflammatory factors that results in the familiar allergy response, including swelling of the nasal membranes, congestion, itching, sneezing, and runny nose. The effectiveness of these medications varies by individual and by drug.

An antihistamine that effectively relieves sinus symptoms in one person may prove totally ineffective for someone else. So if one class or brand of antihistamine doesn’t work, it’s often worthwhile to try another.

• Oral Antihistamines - Most antihistamines used to treat sinusitis are taken in pill form. There are two types of these oral antihistamines available: sedating and nonsedating.

• Sedating Antihistamines - Over-the-counter sedating antihistamines include chlorpheniramine (Chlor-Trimeton), diphenhydramine (Benadryl), brompheniramine (Dimetane), and clemastine (Tavist).

While sedating antihistamines are generally effective, their drawback is that they cross the so-called blood-brain barrier, meaning they enter the brain tissues and can affect the central nervous system.

The most common side effect that results is drowsiness, which can affect up to half of patients who take these antihistamines. Some people find antihistamines make them feel spacey when they take them. Another side effect from these medications is dryness.

In some individuals, the mucous membranes of the mouth and nose become dry and secretions thicken. The sedating side effect of these antihistamines can also be their benefit. Many patients take antihistamines at nighttime to help them fall asleep while controlling sinusitis symptoms.

• Nonsedating Antihistamines - Because they do not cross the bloodbrain barrier, the newer nonsedating antihistamines are less likely than sedating antihistamines to cause drowsiness and other side effects.

Three nonsedating antihistamines are available in oral formulations. Loratadine is sold over the counter as Claritin and Alavert.

A closely related medication, desloratadine (Clarinex), is available by prescription, as is fexofenadine (Allegra). Although a fourth relatively new antihistamine, cetirizine (Zyrtec), is not considered nonsedating, its incidence of associated drowsiness is relatively low.

All four of these antihistamines are available in longer-acting formulations than over-the-counter sedating antihistamines, so you only need to take them once a day.

They’re also produced in combination with pseudoephedrine, in which case there’s a “D” (for decongestant) following the name.

• Antihistamine Sprays - One prescription antihistamine, azelastine (Astelin), is available in a nasal spray to be used twice a day. Like other antihistamines, it’s intended to reduce swelling and relieve congestion by blocking the allergic cascade triggered by histamine.

Azelastine’s advantage is that side effects are minimized because it’s applied directly to the nasal passages, with little absorption into the bloodstream.

Although it works well for some people with sinusitis and allergies. I’ve not found it to be as effective as oral antihistamines are for most. Also, it has an unpleasant taste that some people find intolerable.

Pain Relievers and Cough Suppressants

Along with the three categories I’ve already discussed, two other types of drugs are commonly combined in cold and allergy medications: pain relievers and cough suppressants. Pain relievers include aspirin, acetaminophen (Tylenol), and nonsteroidal anti-inflammatory drugs (Advil, Motrin, Aleve), also known as NSAIDs.

These medications treat both headache pain and the discomfort described as facial pressure due to blocked sinuses. The most common nonnarcotic cough suppressant is dextromethorphan, the active ingredient found in Robitussin and other cough medicines.

More potent cough suppressants contain narcotics, such as codeine, requiring a prescription. Although coughing is not one of the more common sinusitis symptoms, it does occur when postnasal drip drains into the chest, especially when you are lying down at night.

Combination Products

Cold and allergy combination products include one or more drugs from each of the five categories we’ve discussed:

• Decongestants
• Mucus-thinning agents
• Antihistamines
• Pain relievers
• Cough suppressants

Somewhat like a Chinese menu, you can order à la carte or go for a combo plate. Table below shows you some of the most common combinations.

Drug Combinations for Sinusitis

Combination	Brand Names*
Decongestants mucus-thinning agents	OTC Deconsal II Sinutab Non-Drying Sudafed Non-Drying Sinus Prescription Entex-PSE Guaifed-PSE
Decongestants pain relievers	OTC Sinutab Sinus Sudafed Sinus & Cold Sudafed Sinus Headache Tylenol Sinus Day Non-Drowsy
Decongestants antihistamines	OTC Actifed Cold & Allergy Alavert-D Benadryl Allergy & Sinus Benadryl-D Allergy & Sinus Claritin-D Sudafed Sinus & Allergy Sudafed Sinus Nighttime Tavist-D Prescription Allegra-D Zyrtec-D
Decongestants antihistamines pain relievers	OTC Actifed Cold & Sinus Dimetapp Cold & Allergy Drixoral Cold & Flu Benadryl Allergy & Cold Benadryl Allergy & Sinus Headache Benadryl Severe Allergy & Sinus Headache Sinutab Sinus Allergy Sudafed Sinus Nighttime Plus Pain Relief Tylenol Sinus Night Time
Decongestants antihistamines mucus-thinning agents	Prescription Decon-G
Decongestants pain relievers mucus-thinning agents	OTC Tylenol Sinus Severe Congestion

* Generic versions of nonprescription brands also available.

When you are choosing a product, your underlying assumption should be that you want to take as little medication as possible, since there’s no sense in needlessly exposing yourself to side effects.

Symptoms vary by individual and may change from episode to episode. So you need to do a self-evaluation before deciding whether to take a single drug or a combination.

For example, if you have thick mucus but don’t feel congested, then you only need guaifenesin. And if you’re congested but have thin mucus, then you only need pseudoephedrine. Often, however, congestion and thick mucus go hand in hand.

If that’s the case, then choose a product that contains both pseudoephedrine and guaifenesin. As mentioned earlier, antihistamines are most helpful if you have allergies. However, if you’ve found other remedies are ineffective, combining an antihistamine with pseudoephedrine may be beneficial.

Other Medications

Two other medications both available in spray form are less commonly used than the medications I’ve already discussed, but for some people with sinusitis, they can be quite helpful:

• Cromolyn sodium (NasalCrom). This over-the-counter medication is called a mast-cell stabilizer. It is intended to reduce postnasal drip and sneezing caused by allergies.

Normally, upon entering the nose, an allergen triggers the mast cells that line the nasal passages to release histamines, which cause nasal allergy symptoms.

Cromolyn sodium provides a protective layer that shields mast cells from these allergens. It is most helpful when taken in a preventive manner that is, just before you’re exposed to the substance that triggers your nasal allergies.

• Ipratropium (Atrovent). This prescription medication is an anticholinergic agent, meaning it dries up the nose. It seems to work best in individuals whose main problem is excessive production of clear nasal mucus out the front of their nose from either allergies or a cold.

It’s not very effective for those with thick postnasal drip caused by infected sinuses. Ipratropium is available in spray bottles at two different strengths (0.3 percent and 0.6 percent).

Next, we’ll look at nasal steroids, which are some of the most commonly prescribed medications for people with sinusitis.