What treatment options are available for a patient with postnasal drip who has not responded to ipratropium (Ipratropium bromide) and Flonase (fluticasone propionate)?

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Last updated: February 28, 2025 • View editorial policy

From the Guidelines

For a patient with persistent post-nasal drip not responding to ipratropium and Flonase, I recommend adding an oral antihistamine such as loratadine 10mg daily or cetirizine 10mg daily, as they can help reduce mucus production by blocking histamine receptors with minimal sedation, as suggested by the study 1. The patient's condition may be related to allergic rhinitis, and the use of oral antihistamines can be beneficial in reducing symptoms.

  • The study 1 suggests that oral antihistamines, such as loratadine and cetirizine, are effective in reducing nasal symptoms, including post-nasal drip.
  • Additionally, a short course of oral decongestant like pseudoephedrine 60mg every 6 hours (if no contraindications like hypertension or heart disease exist) can be considered to reduce congestion, as mentioned in the study 1.
  • Nasal saline irrigation twice daily using a neti pot or squeeze bottle can physically flush mucus and irritants, and ensuring adequate hydration (at least 8 glasses of water daily) helps thin mucus secretions.
  • If symptoms persist after 2-3 weeks of this combined approach, the patient should be evaluated for potential underlying conditions such as chronic sinusitis, allergies, or gastroesophageal reflux disease, which may require different treatment approaches, as suggested by the study 2.
  • The use of systemic corticosteroids, such as prednisolone, may also be considered for a short course, as shown in the study 2, which demonstrated significant improvement in symptoms and nasal polyp score.
  • However, it is essential to weigh the benefits and risks of systemic corticosteroids, considering the potential side effects and the patient's overall health status.

From the FDA Drug Label

Ipratropium bromide 0.03% does not relieve nasal congestion, sneezing, or postnasal drip associated with allergic or nonallergic perennial rhinitis. The FDA drug label does not answer the question.

From the Research

Treatment Options for Postnasal Drip

For patients with postnasal drip who have not responded to ipratropium (Ipratropium bromide) and Flonase (fluticasone propionate), several alternative treatment options are available:

  • Azelastine nasal spray, which has been shown to be effective in reducing nasal symptoms, including postnasal drip, in patients with allergic rhinitis 3
  • Combination therapy with azelastine nasal spray and fluticasone propionate, which has been demonstrated to be more effective than either agent used alone 3, 4
  • MP29-02, a novel formulation of azelastine hydrochloride and fluticasone propionate in an advanced delivery system, which has been shown to provide superior efficacy in allergic rhinitis patients compared to either monotherapy 4
  • Oral second-generation antihistamines, such as cetirizine, loratadine, or fexofenadine, which may be used on an as-needed basis for mild, intermittent symptoms 5
  • Leukotriene antagonists, such as montelukast, which may be used in combination with other agents for patients with more persistent or severe symptoms 6

Considerations for Treatment Selection

When selecting a treatment option, consider the following factors:

  • Severity and duration of symptoms
  • Presence of co-morbidities, such as sinusitis or asthma
  • Patient age and medical history
  • Previous response to treatment
  • Potential side effects and interactions with other medications

Additional Therapies

Additional therapies that may be considered for patients with postnasal drip include:

  • Sodium cromoglycate, a mast cell stabilizer nasal spray, which may be useful in reducing nasal symptoms 5
  • Pseudoephedrine, an oral vasoconstrictor, which may be used to relieve nasal congestion 5
  • Immunotherapy, which may be considered for patients with specific allergen triggers and persistent symptoms despite pharmacotherapy 5

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.