What is the recommended treatment for a patient presenting with postnasal drip?

Treatment Recommendations for Postnasal Drip

For patients presenting with postnasal drip, first-generation antihistamine/decongestant combinations are the recommended first-line treatment due to their proven efficacy in treating this condition. 1

Diagnostic Approach

Before initiating treatment, determine the likely cause of postnasal drip:

• Allergic rhinitis: Look for sneezing, itchy eyes/ears, seasonal pattern
• Non-allergic rhinitis: Thin watery secretions triggered by odors, temperature changes
• Post-viral/infectious: Recent upper respiratory infection history
• Sinusitis: Facial pain, thick nasal discharge, possible fever
• Physical/chemical irritants: Exposure to workplace irritants, smoke, pollution
• Medication-induced: Use of nasal decongestant sprays (rhinitis medicamentosa)

Treatment Algorithm

First-Line Treatment:

• First-generation antihistamine/decongestant combination (e.g., dexbrompheniramine maleate 6mg + pseudoephedrine 120mg twice daily) 1
  • Start with bedtime dosing for a few days before moving to twice daily to minimize sedation
  • Improvement should be seen within days to 2 weeks
  • First-generation antihistamines work primarily through anticholinergic effects

For Allergic Rhinitis:

• Intranasal corticosteroids (e.g., fluticasone propionate) 1, 2
  • May start to provide relief on first day of use but takes several days for full effectiveness 2
  • Can be used for up to 6 months in adults and children 12+ years
  • Children 4-11 years should use for shortest time necessary (no more than 2 months/year without physician review) 2
• Antihistamines (non-sedating preferred for allergic rhinitis) 1
• Leukotriene inhibitors may be beneficial 1

For Sinusitis:

• For chronic sinusitis: Minimum 3-week course of antibiotics effective against H. influenzae, anaerobes, and S. pneumoniae, plus antihistamine/decongestant for 3 weeks and nasal decongestant for 5 days 1
• For acute sinusitis: Consider waiting 1 week before antibiotics as many cases are viral 1
• Intranasal corticosteroids to reduce inflammation 1

For Non-Allergic Rhinitis:

• Ipratropium bromide nasal spray may be effective due to anticholinergic properties 1
• First-generation antihistamine/decongestant combinations are more effective than newer generation antihistamines 1

For Rhinitis Medicamentosa:

• Discontinue offending nasal decongestant spray (can wean one nostril at a time) 1
• Intranasal corticosteroids may help during withdrawal 1

Important Considerations and Cautions

• Monitor for side effects: Dry mouth, dizziness, sedation, urinary retention (especially in older men), increased blood pressure, glaucoma exacerbation 1
• Newer generation (non-sedating) antihistamines are generally LESS effective for non-allergic causes of postnasal drip 1
• Intranasal steroids are effective for both allergic and non-allergic causes and have minimal systemic absorption 1, 2
• Fluticasone nasal spray does not cause rebound effect like decongestant sprays 2
• Persistent symptoms despite appropriate treatment for 1 week may indicate infection or other serious condition requiring further evaluation 2

When to Refer to Specialist

• Severe sinus pain with thick discharge (possible infection)
• Symptoms persisting after 1 week of appropriate therapy
• Unilateral symptoms or bleeding (possible mass)
• Constant whistling sound (possible nasal damage) 2

By following this treatment approach based on the underlying cause of postnasal drip, most patients should experience significant symptom improvement and better quality of life.