How to choose an effective decongestant

Last week, my husband came home, complaining, “I can’t find Nyquil® at the grocery store! I’m almost out; what will I use if I get the flu?”

Nyquil® used to come in only two options: green or red liquid. Each version had precisely the same ingredients: green NyQuil® was the original flavor, and the red was an attempt at a cherry flavor. These days, there are several more options, each with different formulas.

My husband preferred the older forms of NyQuil® to the ones available today. The original green NyQuil® helped relieve the misery of a stuffy head, headache, and body aches. He could get a decent night’s sleep, which allowed him to recover more quickly.

That original NyQuil® formula had 5 main ingredients: Tylenol® (acetaminophen) for his fever, headache, and body aches, dextromethorphan for his cough, doxylamine, an antihistamine that helped relieve his runny nose, sneezing, and helped him sleep, pseudoephedrine as an effective decongestant for his stuffy nose and sinus pressure, and 25% alcohol, which encouraged his sleep.

Today’s formulas of NyQuil® liquid don’t help my husband’s stuffy nose.

That’s because the company was forced to change the decongestant in Nyquil®. The original version marketed by the Vicks company contained pseudoephedrine, an effective decongestant.

The Food and Drug Administration (FDA) decided to restrict access to pseudoephedrine because it was being diverted into making the street drug methamphetamine, or "meth ."In 2005, the manufacturers of all non-prescription (OTC) products containing pseudoephedrine were forced to remove it.

In its place, the FDA allowed another decongestant: phenylephrine. Unfortunately, the dose of phenylephrine that relieves a stuffy nose has caused severe side effects, like stroke. Because of this, the FDA has limited the amount of phenylephrine to only 1/3 of its effective adult dose. For many people with sinus congestion, taking phenylephrine is no better than taking a sugar pill.

Nyquil® Severe Cold and Flu remains closest to the original Nyquil®, but I don’t recommend using it. It contains phenylephrine, which can increase blood pressure without helping your stuffy nose.

Nyquil® Cold and Flu is the version of Nyquil® we use today. It does NOT contain phenylephrine, so you do not risk it affecting your blood pressure or interfering with blood pressure medications. Whenever my husband has nasal congestion in addition to his fever and body aches, he can take pseudoephedrine in addition to Nyquil®.

I buy the version of Sudafed® with pseudoephedrine, which is only available "behind the counter." I prefer red-coated 30mg generic tablets over the white 60mg tablets or 120mg long-acting capsules.

What if you have both a stuffy and a runny nose? I have found the most effective way to relieve a runny and stuffy nose is a combination of pseudoephedrine with triprolidine, an antihistamine.

Imagine you are a surgeon who wakes up with a head cold. Even wearing a surgical mask, you wouldn’t want your nose to drip or to sneeze on your patient while bent over, performing a procedure, would you? And, as many of us have experienced during the COVID pandemic, if you have nasal congestion, putting on a face mask can make you feel like you are suffocating.

Triprolidine helped dry up the runny nose and ease the sneezing of afflicted surgeons and surgical nurses, and pseudoephedrine relieved their stuffy noses. The combination of these two agents is called Actifed®, which rarely causes drowsiness, which is another benefit.

Decades later, I find this STILL the best remedy for a stuffy, runny nose and sneezing. I make sure to keep a generic version of this formula on hand at all times. Actifed® (triprolidine/pseudoephedrine) is restricted. You will need to ask for it at a pharmacy, and it will require photo identification and your signature.

Here are 4 tips when choosing a decongestant:

1.         Avoid phenylephrine. 

Phenylephrine is NOT effective at the doses allowed by the FDA. Unfortunately, the amount that relieves nasal congestion can cause life-threatening elevations in your blood pressure.

2.         Request the restricted version of Sudafed®.

It's worth the hassle of purchasing pseudoephedrine in order to have an effective decongestant in my medicine cabinet.

3.         For rapid relief, use Afrin® nasal spray.

Afrin® (oxymetazoline) nasal spray has been used for years to ease a stuffy and runny nose. Nose spray is less likely to trigger high blood pressure than oral decongestants. Use Afrin® short-term only; after 3-5 days in a row, it loses effectiveness.

4.         If your nose is both running and stuffed up, try Actifed®.

You’ll have to ask the pharmacy for generic Actifed® (triprolidine/pseudoephedrine) tablets.

Dr. Louise Achey, Doctor of Pharmacy, is a 43-year veteran of pharmacology and author of Why Dogs Can’t Eat Chocolate: How Medicines Work and How YOU Can Take Them Safely. Get clear answers to your medication questions at her website and blog TheMedicationInsider.com.

Ó2023 Louise Achey