Which decongestants to use that don’t have phenylephrine, according to experts

Which decongestants to use that don’t have phenylephrine, according to experts

Walk down the cold and flu aisle in any drugstore and you’ll spot dozens of over-the-counter drugs that contain the decongestant phenylephrine, the ingredient that a Food and Drug Administration advisory committee on Tuesday said does not work.

Phenylephrine is found in a wide range of cold and flu medications, including Sudafed PE, Benadryl Allergy D Plus Sinus and Vicks DayQuil Cold and Flu Relief.

Here’s what experts say are effective alternatives to relieve nasal congestion. 


Pseudoephedrine, the decongestant found in Sudafed, is highly effective in helping people with stuffy noses breathe more easily, said Dr. Maryann Amirshahi, a medical toxicologist and a professor of emergency medicine at Georgetown University School of Medicine. 

The downside, Amirshahi said, is that the medication is not over the counter but “behind the counter”  — meaning that it doesn’t require a prescription but people must request it from a pharmacist to buy it. 

In 2006, pseudoephedrine was moved behind the counter and limits were placed on how much a person could buy as a means to deter people from using it to make methamphetamine. 

Phenylephrine — the ingredient deemed ineffective — took off in popularity as a replacement for pseudoephedrine. 

Mike Koelzer, a pharmacist in Grand Rapids, Michigan, said he doesn’t expect any issues with more people requesting pseudoephedrine. Pharmacists have long known that phenylephrine was potentially ineffective and have been recommending alternatives like pseudoephedrine.

Amirshahi noted that pseudoephedrine comes with side effects, including dizziness, nervousness and trouble sleeping. It may also increase blood pressure, a potential drawback for people with heart problems.

“But that being said, if you’re using it for a short-term course of therapy, and not chronically, that’s really not as much of an issue because you’re only going to be using it for a few days,” she said. 

Nasal sprays

While people tend to prefer taking a pill to using a nasal spray, the sprays are effective at relieving congestion, said Dr. Vin Gupta, a pulmonologist and an affiliate faculty member at the University of Washington in Seattle.

For people who can’t take pseudoephedrine, Gupta, who is an MSNBC medical contributor, said he recommends using a corticosteroid nasal spray like Flonase, a common over-the-counter allergy medication that can also relieve congestion. 

Phenylephrine is also still thought to be effective when used as a nasal spray, said Dr. Wynne Armand, a primary care physician at Massachusetts General Hospital.

The FDA panel on Tuesday specifically considered the effectiveness of oral phenylephrine. Studies have shown that when taken as a pill, too much of the drug is broken down in the body before it gets to the nose to relieve congestion. With a nasal spray, it’s delivered directly to the nose.

Armand said that people using decongestant nasal sprays should not use them for more than three days. Prolonged use can lead to so-called rebound congestion, she added.

Oxymetazoline, a common ingredient in over-the-counter nasal sprays including Afrin and Zicam, is also an effective alternative, Koelzer said. Like phenylephrine nasal spray, prolonged use of oxymetazoline nasal spray can also cause rebound congestion.


Dr. Purvi Parikh, the national spokesperson for the Allergy & Asthma Network, an advocacy group, said that she usually does not recommend pseudoephedrine to her patients because of its effects on blood pressure.

Instead, she recommends oral antihistamines like Zyrtec, Allegra and Claritin.

The medications are commonly used for allergies and hives, but can also be used to get rid of nasal congestion. They work in a slightly different way than decongestants, which reduce the swelling of blood vessels in the nasal passages. Antihistamines also reduce swelling and irritation in the nasal passages, but by blocking the chemicals in the body responsible for those reactions.

“These medications actually treat the underlying inflammation in addition to providing relief,” said Parikh, who is also an allergist and immunologist at Allergy and Asthma Associates of Murray Hill in New York City. 

What can help kids with stuffy noses?

For children, a stuffy nose can be more severe because kids’ nasal passages are much smaller than adults, said Dr. Buddy Creech, a pediatric infectious disease expert at the Vanderbilt University Medical Center in Nashville, Tennessee.

But there are few options available to treat a child’s congestion. The FDA says that children under two should not be given any type of cold and flu that contains a decongestant or an antihistamine because of dangerous side effects. For children ages two to four, the FDA urges caution. 

In the first years of a child’s life, Creech said parents could use a bulb syringe, used to remove mucus from a baby’s mouth and nose, to help relieve nasal congestion. 

Instead of decongestants, Children’s Tylenol and Children’s Advil can be given to children to help relieve pain from the congestion, he said. 

In some cases, teens can take pseudoephedrine, Creech said. 

“It is difficult because, given the doses that you really need it to be most effective, it does have those side effects of mental alertness but also heart racing,” he said. “So if it is used, we would only use it with direct supervision and keeping the drug in a safe place.”

Koelzer said that simple, nonmedical approaches can also help, like making sure kids get plenty of rest and water when they are sick. Maybe a popsicle, too, he said.  

For children, “about the only things I’ll recommend for a cold might be some Tylenol if there’s some fever, and possibly some dextromethorphan to calm the cough, and I only do that if they’re coughing so hard that they’re going to throw up,” he said, referring to an ingredient found in over-the-counter cough medicines.

Creech said steam from a humidifier or a hot shower can help break up the mucus. The opposite is also helpful: Going out in the cold air.

“That coldness can constrict or tighten the blood vessels in the nose and that can actually cause them to get a little bit of relief,” he said. 

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