The History, Implications and Treatment of Rhinitis Medicamentosa (RM.)
Rhinostat Labs is the Rhinitis Medicamentosa Company. Since 1999, we have been conducting research and providing a non-invasive treatment option that maintains comfortable airflow as RM patients are weaned from the decongestant nasal sprays. This page contains a history of RM, a summary of the medical research and the impact it has on the lives of RM patients.
When Did Rhinitis Medicamentosa Appear In Medical Research?
It has been known since the 1940s that the use of topical decongestants could induce nasal congestion leading to the prolonged use of these medications. During this early time period, topical nasal spray formulations contained ephedrine. In 1945, “Abuse of Nasal Vasoconstrictor Medications” appeared in an article by B.M. Kully, published in the Journal of the American Medical Association (JAMA.) At the time, more than 240 different preparations were available via prescription. Dr. Kully’s article discusses the disadvantages of widespread prescribing of these medications. See Citation #1 below.
Perhaps the first “sounding of the alarm” was presented by Noah Fox, MD in January 1931. An article entitled “The Chronic Effect Of Epinephrine And Ephedrine On The Nasal Mucosa” discussed the effect of these medications on animal subjects and the potential for overuse in humans. See Citation#2 below.
In summary, if you or someone you know is struggling with RM, this condition has been documented for almost a century. In addition, individuals who suffer from RM are far from alone. There are more than 2.4 million search queries per year related to RM. Many ENT clinics report that 5% – 7% of their patients have RM. While no exact numbers exist, the worldwide RM patient population could potentially include 7-10 million individuals.
What Is The Most Common Decongestant Used By Rhinitis Medicamentosa Patients?
Modern vasoconstrictors in use today (Oxymetazoline, Xylometazoline and Phenylephrine) were first introduced in the late 1950’s and early 1960’s. Afrin (containing Oxymetazoline) was introduced as a prescription medication in 1966. In 1975, Afrin became available over-the-counter (OTC.) Widespread advertising for the product began in 1986.
Based upon our research since 1999 at Rhinostat Labs, Afrin (or other generic Oxymetazoline equivalents) remain the most popular OTC topical decongestant nasal sprays in use today. 86% of the patients Rhinostat interacts with are using decongestant sprays containing Oxymetazoline HcL as the active ingredient, followed by Phenylephrine (9%) and Xylometazoline (3%.) Other ingredients (such as Naphazoline) and combination formulations make up the remaining 2%
What Is The Pathophysiology Of Rhinitis Medicamentosa?
The pathophysiology of RM is not completely understood. A review of the medical literature on RM reveals some disagreement on this. Some authors propose that is caused by interstitial oedema, while others suggest the root cause is vasodilation. There is also disagreement as to whether or not tachyphylaxis (drug tolerance) can occur with Oxymetazoline and Xylometazoline based decongestants. Our own research indicates that long term RM patients typically administer doses in regular 5-7 hour intervals and that this pattern may persist for decades. As such, we do not believe that a tolerance to these medications develops even with extended use.
What Are The Treatment Options For Rhinitis Medicamentosa?
While there is disagreement on the pathophysiology, there is good agreement on the cornerstone of an RM treatment plan. Patients must discontinue their use of the sprays. The abrupt withdrawal of the decongestants initiates a 4-7 day period of nasal congestion which is too uncomfortable for most RM patients to endure. This is the primary reason why the treatment of RM often fails. Various medications (typically prednisone, fluticasone) are prescribed to reduce the congestion and discomfort, but the reduction in nasal airflow remains the primary treatment obstacle. Many RM patients return to the decongestants in as few as 12-18 hours after initiating treatment.
A landmark study was conducted in 1997 which examined the benefits of fluticasone (Flonase) vs. placebo in the treatment of RM patients. Figure 3 of the study shows the comparative airflow in the fluticasone group vs. the placebo group. The results show that there is no discernable improvement in measured airflow associated with the use of fluticasone to treat RM. Notwithstanding these results, fluticasone is a popular treatment option in clinical practice. Although there was a measurable reduction in mucosal swelling associated with fluticasone, the impediment to airflow causes many of these patients to return to the decongestants.
A copy of the fluticasone study is available on our medical research page.
What Would The Ideal Treatment Of Rhinitis Medicamentosa Include?
The ideal treatment for RM would preserve airflow throughout the withdrawal process. This is precisely what Rhinostat is designed to provide. Using Rhinomanometry (the study of nasal airflow) we can see that patients who are precisely and gradually weaned using Rhinostat maintain normal airflow throughout the weaning process. Rhinostat is available without a prescription directly from Rhinostat Labs.
Does The Preservative Benzalkonium Chloride Contribute To Rhinitis Medicamentosa?
Nearly all OTC decongestant sprays contain the preservative benzalkonium chloride to inhibit microbial growth. Multiple studies have shown that this contributes to mucosal swelling and inhibits the normal function of nasal cilia. For this reason, Rhinostat kits are preservative free and individually formulated for each patient depending upon the active ingredient in their current decongestant spray.
What Is The Impact On The Lives Of Rhinitis Medicamentosa Patients?
Only those who have been addicted to these sprays are able to understand the impact that RM has on their lives. Rhinostat has documented many cases of individuals who have been addicted to decongestant nasal sprays for more than forty years.
If deprived of the medication, RM patients (who are otherwise healthy and asymptomatic) often describe a feeling of anxiety, panic, suffocation, and claustrophobia. This entire physiologic and psychological phenomenon is something that Rhinostat is intimately familiar with and it remains the subject of our focused research, which began in 1999.
It is not uncommon for these people to keep their problem a secret from their families, co-workers, friends and even their physicians. They excuse themselves from social settings and often wake up in the middle of the night to administer a dose. They have learned how to integrate the use of the sprays into their daily routines. They keep a bottle of decongestant in their pocket, purse, nightstand, glove box, backpack, attaché case and anywhere else necessary to ensure that it is readily available when needed. They endure embarrassment and discomfort when habitually purchasing the sprays at the local pharmacy. They will often “rotate” their purchasing locations so as not to attract attention.
How Can Rhinostat Help In The Treatment Of Rhinitis Medicamentosa?
#1 Kully Bm. The Use And Abuse Of Nasal Vasoconstrictor Medications. Jama. 1945;127(6):307–310
#2 Fox N. The Chronic Effect Of Epinephrine And Ephedrine On The Nasal Mucosa. Arch Otolaryngol. 1931;13(1):73–76.