What are the treatment options for post nasal drip?

Medical Management of Post Nasal Drip

First-generation antihistamine/decongestant combinations are the most effective first-line treatment for post nasal drip, particularly when used in combination with nasal corticosteroids for persistent symptoms. 1

Understanding Post Nasal Drip (Upper Airway Cough Syndrome)

Post nasal drip (PND) refers to the sensation of mucus draining from the back of the nose into the throat. It is now more accurately termed Upper Airway Cough Syndrome (UACS) since the mechanism may involve both actual drainage of secretions and direct irritation of upper airway cough receptors 1. UACS is the most common cause of chronic cough in adults, accounting for up to 41% of cases 1.

Causes of Post Nasal Drip

Treatment should be targeted to the underlying cause:

1. Allergic rhinitis - seasonal or perennial allergen exposure
2. Non-allergic rhinitis - vasomotor, medication-induced, hormonal
3. Sinusitis - acute or chronic
4. Post-viral upper respiratory infections
5. Physical or chemical irritants - occupational exposures, smoke
6. Rhinitis medicamentosa - rebound congestion from overuse of topical decongestants
7. Gastroesophageal reflux disease (GERD) - can cause "reflux PND"

Treatment Algorithm

First-line Therapy:

1. First-generation antihistamine/decongestant (A/D) combinations:

   • Dexbrompheniramine maleate (6 mg twice daily) plus sustained-release pseudoephedrine (120 mg twice daily) OR
   • Azatadine maleate (1 mg twice daily) plus sustained-release pseudoephedrine (120 mg twice daily)
   • These combinations have proven efficacy in randomized controlled trials 1
   • First-generation antihistamines work primarily through anticholinergic effects

2. Nasal corticosteroids:

   • Fluticasone propionate nasal spray 50 mcg (1-2 sprays per nostril once or twice daily) 2
   • Particularly effective for allergic rhinitis and non-allergic eosinophilic rhinitis
   • May take several days to reach maximum effectiveness 2

For Specific Underlying Causes:

Allergic Rhinitis:

• Nasal corticosteroids (first choice)
• Second-generation antihistamines (less effective for non-allergic causes)
• Leukotriene receptor antagonists
• Nasal cromolyn sodium
• Allergen avoidance when possible 1

Non-allergic/Vasomotor Rhinitis:

• Ipratropium bromide nasal spray (anticholinergic)
• Azelastine nasal spray (2 sprays per nostril twice daily) 3
• First-generation A/D combinations

Sinusitis:

• Antibiotics effective against H. influenzae, anaerobes, and S. pneumoniae for at least 3 weeks
• Nasal corticosteroids for at least 3 months
• Short course (5 days) of topical decongestant
• Consider endoscopic sinus surgery for refractory cases with anatomic obstruction 1

Post-viral Upper Respiratory Infection:

• First-generation A/D combinations
• Ipratropium bromide nasal spray
• Newer generation antihistamines are less effective 1

Rhinitis Medicamentosa:

• Discontinuation of offending topical decongestant (may wean one nostril at a time)
• Nasal corticosteroids during withdrawal period 1

For Refractory Cases:

1. Nasal saline irrigation:

   • High-volume saline irrigation may be more effective than low-volume for purulent rhinorrhea 1

2. Herbal medicines:

   • BNO1016 tablets, Pelargonium sidoides drops, or Myrtol capsules have shown efficacy in some studies 1

3. Posterior nasal nerve ablation:

   • Newer procedure showing promise for medically refractory cases
   • 72.5% of patients report at least 30% improvement in PND symptoms 4

Important Considerations and Caveats

• Initiate first-generation antihistamines at bedtime for a few days before going to twice-daily therapy to minimize sedation 1

• Monitor for side effects of decongestants: insomnia, urinary retention (especially in older men), jitteriness, tachycardia, hypertension, and increased intraocular pressure in glaucoma patients 1

• Avoid long-term use of topical decongestants (>3-5 days) to prevent rhinitis medicamentosa 1

• Consider GERD treatment if reflux symptoms are present or if other treatments fail 1

• Newer generation (non-sedating) antihistamines are less effective for non-allergic causes of post nasal drip 1

• Antibiotics should not be prescribed for post-viral rhinosinusitis as they show no benefit in cure or duration of disease 1

• Treatment duration: For chronic sinusitis with PND, continue intranasal corticosteroids for at least 3 months after symptoms resolve 1

By following this structured approach to the diagnosis and treatment of post nasal drip, most patients will experience significant symptom improvement and better quality of life.