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Original Research (Original Article) 


Khalid A. Alyahya et al, 2020;4(2):303–308.

International Journal of Medicine in Developing Countries

Awareness of the Saudi population regarding nasal decongestants use for allergic rhinitis and their side effects

Khalid A. Alyahya1, Zahraa A. Alsubaie1*, Zainab A. Almubarak1, Ahmed A. Al-Khalifah1, Abdullah H. Alawadh1

Correspondence to: Zahraa A. Alsubaie

*College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia.

Email: zahraaalsubaie [at] gmail.com

Full list of author information is available at the end of the article.

Received: 21 October 2019 | Accepted: 03 January 2020


ABSTRACT

Background:

Systemic and topical nasal decongestant drugs are widely used in otorhinolaryngology and general practice among the Saudi population. They are potent vasoconstrictive agents that are usually used in reducing congestion of nasal and ocular mucous membranes in so many diseases such as allergic rhinitis, acute rhinosinusitis, and conjunctivitis. However, long-term use of these drugs may lead to some side effects, such as rhinitis medicamentosa. This study was aimed to evaluate the awareness of the Saudi population regarding the side effects of nasal decongestant drugs.


Methodology:

This is a questionnaire-based cross-sectional study including Saudi adults and excluding health care workers. The questionnaire was developed and distributed online from the period of October and November 2017. The questionnaire assessed demographical data, knowledge on allergic rhinitis, and knowledge on the side effects of decongestants and rhinitis medicamentosa.


Results:

A total of 575 participants who fulfill the criteria successfully filled the questionnaires. 60.2% of those were males, 73.2% reside in cities, 89.4% were 40 years and younger, 53.0% were married, and only 30.3% had education level lower than college. 39.3% were able to identify “hereditary as the etiological factor for allergic rhinitis”. 68.5% had used nasal decongestants (66.5% had used them with a prescription and 31.5% without a prescription).


Conclusion:

Nasal decongestants are considered as one of the most commonly available over the counter medications. It is advised that nasal decongestants should be only available on a prescription basis. Health workers and advocates are recommended to improve patient awareness related to nasal decongestants.


Keywords:

Awareness, Saudi population, nasal decongestants, allergic rhinitis, side effects.


Introduction

Systemic and topical nasal decongestant drugs are widely used in otorhinolaryngology and general practice among the general population. Topical nasal decongestants are easily accessible over the counter drugs. Nasal decongestant drugs are alpha-adrenergic agonists such as oxymetazoline, xylometazoline, phenylephrine hydrochloride, pseudoephedrine, naphazoline hydrochloride, tetrahydrozoline hydrochloride, clomazone, tramazoline, hydroxyamphetamine, tuaminoheptane, and phenylpropanolamine are sympathomimetic agents that imitate sympathetic central nervous system activity in the body [1]. They are strong vasoconstrictive agents and are commonly used in reducing nasal congestion to manage some nasal conditions such as allergic rhinitis, rhinosinusitis, allergies of the upper respiratory tract, nasal polyps, and hypertrophy [1,2]. They are rapid-acting with quick relief of symptoms. Selective adrenoceptor agonists, such as brimonidine tartrate, are also used for ocular mucosa to treat other conditions like conjunctivitis, ocular hypertension, and open-angle glaucoma [24]. Long-term use of nasal decongestants may induce compensatory vasodilation in the nasal arteries. The nasal mucosa consists of both capacitance and resistance blood vessels. The resistance vessels compromise arteriovenous anastomoses, arterioles, and small arteries drain into the capacitance vessels, which are made up of venous sinusoids and small veins. On one hand, venous sinusoids are innervated by sympathetic fibers and when they are activated, these nerves release norepinephrine, which binds to α1 and α2 receptors. This interaction leads to reduce nasal congestion by decreasing blood flow to that area and increasing sinus emptying in the capacitance vessels. On the other hand, resistance vessels are innervated by parasympathetic fibers which contribute to vasodilation and nasal congestion. Parasympathetic nerves release both acetylcholine, which increases rhinorrhea, and vasoactive intestinal peptide, which causes vasodilation. In this case, decreased production of endogenous sympathetic norepinephrine because of the negative feedback mechanism, the sympathetic nerves may be unable to maintain vasoconstriction because norepinephrine release now is suppressed. This will induce vasodilation that results in the development of rebound congestion [5,6]. Therefore, topical nasal decongestants should not be used for more than five days [1]. Rebound congestion or rhinitis medicamentosa is the frequent adverse effect that happens due to the misuse of nasal decongestant drugs, especially in their topical form [7]. In many countries around the world, the use of decongestion drugs is limited to a maximum of 10 days because of the risk of developing rhinitis medicamentosa [6]. For example, in the United State, the incidence of rhinitis medicamentosa most of the time is underreported because of the over-the-counter availability of these decongestant drugs. In a study that included 119 allergies, it is estimated that about 6.7% of them had rhinitis medicamentosa. Also, in another study that conducted over 10 years in the otolaryngology office, the incidence rate of rhinitis medicamentosa was 1% [810]. Moreover, in another study, an ENT resident diagnosed rebound congestion in 52 out of 100 consecutive non-infectious patients who presented to the clinic with nasal obstruction [11]. Other side effects include, on rare occasions, serious adverse effects may occur due to overdose. These adverse effects include seizure, headache, hypertensive crisis, stroke, tachycardia, and palpitation [7]. These products are available over the counter and can be the subject of abuse if used for an extended period, which leads to the development of rhinitis medicamentosa. Rhinitis medicamentosa is especially difficult to control and no treatment was available to cure [7,1218]. This study aims to evaluate the knowledge of people regarding the side effect of nasal decongestant drugs.


Subjects and Methods

This is a cross-sectional study that involves the Saudi population both female and male. It was conducted between October and November 2017. Data were collected online by a structured electronic survey. The sample was designed considering a confidence level of 95% and 5% sample errors. The sample size was 602. Adult Saudi citizens were included in this study. Non-Saudi residents, children, and health care professionals were excluded from this study. Questionnaire development was based on previously published questionnaires and was assessed by an expert to approve validity [1,12]. The assessment will be administered after obtaining consent. The population are going to answer the questions related to the use of nasal decongestants in the form of three separate sections: 1) patient’s biographical data—the social economic cultural stage will be calculated by using parameters like gender, age, education level, and residency; 2) questions related to allergic rhinitis, including etiology, triggers, and clinical features; 3) habits of nasal decongestants use, frequency of use, whether the drug is used through medical prescription, improvement of symptoms after usage, worsening after discontinuing the drug and the side effects of long-term use of drug as we aim to measure the population’s level of awareness regarding the side effects of long-term usage of nasal decongestants. The developed questionnaire was piloted to check for feasibility, time management, and acceptability of the questions and to facilitate any needed modifications before the main study. The pilot results were not included in the final data analysis.

The researchers used a multipart questionnaire to assess the awareness of participants, health behavior, biographical and socioeconomic characteristic (i.e., including age, gender, place of residence, income, smoking status, and years of formal education). Ethical approval was granted from both King Faisal University and the directorate of health before the study was conducted. Collected data were obtained through a computerized questionnaire that was accessible online and distributed through social networks. The data were recorded in Microsoft excel in 2016. Then, data were analyzed using Statistical Package for the Social Sciences version 21. Basic frequencies were used for categorical variables, and means and standard deviations were calculated for continuous variables. Chi-square testing was used to determine which factors associated with cardiovascular disease knowledge. Analysis results with a P-value of less than 0.05 were considered as significant.


Results

A total of 602 participants filled the study questionnaire. Twenty-seven participants who were not fulfill the inclusion criteria were excluded. The end sample included 575 participants who completed the questionnaire. 60.2% of those were males, 73.2% reside in cities, 89.4% were 40 years and younger, 53.0% were married, and only 30.3% had education level lower than college. Participant demographic characteristics are presented in Table 1.

Upon assessment of the etiological factors for allergic rhinitis, 39.3% were able to identify “hereditary as the etiological factor”. Educational level was significantly associated (p-value = 0.001 < 0.05) with the identification of the etiological factor for allergic rhinitis. Figure 1 represents the most commonly chosen symptoms of allergic rhinitis.

Table 1. Demographic and clinical characteristics.

Variables Frequency (%)
Gender
Male 374 (60.2%)
Female 282 (39.8%)
Residency
Cities 421 (73.2%)
Villages 154 (35%)
Age
40 years and younger 485 (89.4%)
41 years and older 90 (10.6%)
Marital status
Married 305 (53.0%)
Single 262 (45.6%)
Other 8 (1.4%)
Education
High school and lower 174 (30.3%)
College and higher 401 (69.7%)

In this study, 68.5% had used nasal decongestants and out of those, 66.5% had used them with a prescription and 31.5% had used them without a prescription (Figure2). Although assessing the awareness of nasal decongestants adverse effects, half of the sample (54.6%) were able to identify that Nasal decongestants DO have Adverse effects, 5.6% had chosen no, 29% chose maybe, and 10.8% chose No idea (Figure3). The level of awareness regarding the development of adverse events after 3–5 days was assessed, and it showed that 28% chose yes, 31.1% chose no, and 40.7% chose “I don’t know” (Figure 4). The method of prescription was significantly associated with Age (p-value < 0.05). Table 2 represents the frequency of nasal decongestants use.

Figure 1. Most commonly chosen symptoms of allergic rhinitis.

Figure 2. Comparison between using of nasal decongestants by prescription.

In those who had used nasal decongestant, out of 447, 57.5% had noticed a significant improvement in their symptoms, 36.5% had noticed a mild improvement, and 6% did not notice any improvement at all (Figure 5).

Figure 3. Awareness of nasal decongestants adverse effects.

Figure 4. Level of Awareness Regarding the development of adverse effects after 3–5 days.

Table 2. Frequency of nasal decongestants use.

Variables Frequency (%)
Number of times in a day
Once 191 (47.7%)
2-3 times 191 (47.7%)
more than 4 times 65 (14.5%)
Number of times per day
1-3 days 111 (28.24%)
4-5 days 318 (66.5%)
More than 5 days 25 (5.23%)

The extended use of nasal decongestants per day was significantly associated with age (>40 years) (p-value < 0.05). However, extended use of nasal decongestant was not significantly associated with other factors (p-value > 0.05), such as academic level, marital status, gender, and residency.


Discussion

Nasal decongest is widely available in Saudi Arabia’s prescription. Nasal decongest can be taken as “Over the counter” easily. According to this study, 31.5% had used them without prescription. Nasal decongestants are considered as the most effective drugs that are used for rapid relief nasal obstruction. With their frequent usage, local adverse reactions are frequent. In this study, males presented around 60.2% while in another study the gender breakdown of the sample was 76.7% [1]. In relation to allergic rhinitis, the most chosen etiological factors for allergic rhinitis were hereditary as the etiological factor of 39.3%. Educational level was significantly associated with the identification of the etiological factor for allergic rhinitis. The most commonly chosen symptom in the clinical picture of allergic rhinitis was sneezing and the least chosen symptom was a nasal itch. Other study showed sneezing was the most common symptom thought to be related with the allergy-related symptom, whereas loss of smell was the least one [5], the majority of our sample have been used nasal decongest for almost 4–5 days. However, 5.23% of the population have used for more than 5 days. Morris et al. observed an increase in nasal resistance after 3 days of treatment with oxymetazoline in healthy subjects [6]. Other authors recommend that present products be used only for “emergencies” and for not more than three consecutive days [7]. Our results demonstrated an upsurge in knowledge related to the side effects of nasal decongestants. Here, 56.2% of people were aware that it does have a side effect, 5.6% have chosen no, 29% chose maybe, and 10.8% chose No idea. We have also assessed level of awareness regarding the development of adverse events after 3–5 days, 28% chose yes, 31.1% chose no, and 40.7% chose “I don’t know.” The method of prescription was significantly associated with Age (p-value <0.05). In those who have used nasal decongestant, out of 447, 57.5% have noticed a significant improvement in their symptoms, 36.5% have noticed a mild improvement, and 6% did not notice any improvement at all.

Figure 5. Improvement after nasal decongestants.


Conclusion

In conclusion, nasal decongestants are considered as one of the most commonly available over the counter medications. Self-medication and lack of knowledge on nasal decongestants’ side effects may lead to complications to their users. Over the counter availability of nasal decongestants with no prescription may lead the population to believe that their use is free of risks and adverse effects. It is advised that nasal decongestants should be only available on a prescription basis. Health workers and advocates are recommended to improve patient awareness related to nasal decongestants safe use and side effects.


List of Abbreviations

PRO Patient-reported outcomes


Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

Ethical approval was granted from both King Faisal University and the directorate of health before the study was conducted. King Faisal University, College of Medicine, 2/1/2019.


Author details

Khalid A. Alyahya1, Zahraa A. Alsubaie1, Zainab A. Almubarak1, Ahmed A. Al-Khalifah1, Abdullah H. Alawadh1

1. College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia


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How to Cite this Article
Pubmed Style

Alyahya KA, Alsubaie ZA, Almubarak ZA, Al-Khalifah AA, Alawadh AH. Awareness of the Saudi population regarding nasal decongestants use for allergic rhinitis and their side effects. IJMDC. 2020; 4(2): 303-308. doi:10.24911/IJMDC.51-1571640524


Web Style

Alyahya KA, Alsubaie ZA, Almubarak ZA, Al-Khalifah AA, Alawadh AH. Awareness of the Saudi population regarding nasal decongestants use for allergic rhinitis and their side effects. https://www.ijmdc.com/?mno=70432 [Access: October 15, 2021]. doi:10.24911/IJMDC.51-1571640524


AMA (American Medical Association) Style

Alyahya KA, Alsubaie ZA, Almubarak ZA, Al-Khalifah AA, Alawadh AH. Awareness of the Saudi population regarding nasal decongestants use for allergic rhinitis and their side effects. IJMDC. 2020; 4(2): 303-308. doi:10.24911/IJMDC.51-1571640524



Vancouver/ICMJE Style

Alyahya KA, Alsubaie ZA, Almubarak ZA, Al-Khalifah AA, Alawadh AH. Awareness of the Saudi population regarding nasal decongestants use for allergic rhinitis and their side effects. IJMDC. (2020), [cited October 15, 2021]; 4(2): 303-308. doi:10.24911/IJMDC.51-1571640524



Harvard Style

Alyahya, K. A., Alsubaie, . Z. A., Almubarak, . Z. A., Al-Khalifah, . A. A. & Alawadh, . A. H. (2020) Awareness of the Saudi population regarding nasal decongestants use for allergic rhinitis and their side effects. IJMDC, 4 (2), 303-308. doi:10.24911/IJMDC.51-1571640524



Turabian Style

Alyahya, Khalid A., Zahraa A. Alsubaie, Zainab A. Almubarak, Ahmed A. Al-Khalifah, and Abdullah H. Alawadh. 2020. Awareness of the Saudi population regarding nasal decongestants use for allergic rhinitis and their side effects. International Journal of Medicine in Developing Countries, 4 (2), 303-308. doi:10.24911/IJMDC.51-1571640524



Chicago Style

Alyahya, Khalid A., Zahraa A. Alsubaie, Zainab A. Almubarak, Ahmed A. Al-Khalifah, and Abdullah H. Alawadh. "Awareness of the Saudi population regarding nasal decongestants use for allergic rhinitis and their side effects." International Journal of Medicine in Developing Countries 4 (2020), 303-308. doi:10.24911/IJMDC.51-1571640524



MLA (The Modern Language Association) Style

Alyahya, Khalid A., Zahraa A. Alsubaie, Zainab A. Almubarak, Ahmed A. Al-Khalifah, and Abdullah H. Alawadh. "Awareness of the Saudi population regarding nasal decongestants use for allergic rhinitis and their side effects." International Journal of Medicine in Developing Countries 4.2 (2020), 303-308. Print. doi:10.24911/IJMDC.51-1571640524



APA (American Psychological Association) Style

Alyahya, K. A., Alsubaie, . Z. A., Almubarak, . Z. A., Al-Khalifah, . A. A. & Alawadh, . A. H. (2020) Awareness of the Saudi population regarding nasal decongestants use for allergic rhinitis and their side effects. International Journal of Medicine in Developing Countries, 4 (2), 303-308. doi:10.24911/IJMDC.51-1571640524