What are the next steps for a patient with post nasal drip who is not responding to Avamys (fluticasone furoate)?

Management of Post Nasal Drip Not Responding to Fluticasone Furoate (Avamys)

For patients with post nasal drip not responding to intranasal corticosteroids like Avamys (fluticasone furoate), the next step should be adding a first-generation antihistamine/decongestant combination, which has been shown to be consistently efficacious in treating upper airway cough syndrome.

Assessment of Treatment Failure

When a patient with post nasal drip fails to respond to intranasal corticosteroids, consider:

• Duration of treatment (minimum 2-8 weeks is often needed) 1
• Adherence to proper administration technique
• Underlying etiology that may not respond to corticosteroids alone

Next Treatment Steps

1. Add First-Generation Antihistamine/Decongestant Combination

• First-line option: First-generation antihistamine plus decongestant combination 1
  • Examples: dexbrompheniramine maleate (6 mg twice daily) or azatadine maleate (1 mg twice daily) plus sustained-release pseudoephedrine sulfate (120 mg twice daily)
  • These have been shown to be consistently efficacious in both acute and chronic cough associated with post nasal drip 1
  • Note: Newer generation (non-sedating) antihistamines have been found to be less effective for non-allergic causes of post nasal drip 1

2. Consider Alternative Diagnoses

• Evaluate for underlying conditions that may require specific treatment:
  • Chronic sinusitis (requiring antibiotics)
  • Gastroesophageal reflux disease (GORD)
  • Allergic rhinitis (requiring allergen avoidance)
  • Rhinitis medicamentosa (requiring discontinuation of topical decongestants)

3. Additional Treatment Options

• For suspected bacterial sinusitis: Antibiotics for minimum 3 weeks (effective against H. influenzae, anaerobes, and S. pneumoniae) 1
• For rhinorrhea-predominant symptoms: Consider ipratropium bromide nasal spray 1
• For nasal congestion: Short-term topical decongestants (<7 days to prevent rhinitis medicamentosa) 2
• For all patients: Saline nasal irrigation (may help with symptom relief) 1

Treatment Algorithm Based on Suspected Etiology

If Allergic Rhinitis Suspected:

1. Continue intranasal corticosteroids
2. Add non-sedating antihistamine
3. Consider leukotriene receptor antagonists 1

If Non-Allergic/Vasomotor Rhinitis Suspected:

1. Add first-generation antihistamine/decongestant combination
2. Consider ipratropium bromide nasal spray 1

If Chronic Sinusitis Suspected:

1. Antibiotics (amoxicillin-clavulanate, cefuroxime axetil) for at least 3 weeks
2. Continue intranasal corticosteroids
3. Consider sinus imaging if no improvement 1

Special Considerations

• Caution with decongestants: Monitor for insomnia, urinary retention (especially in older men), jitteriness, tachycardia, hypertension, and increased intraocular pressure 1
• Sedation management: Consider initiating antihistamine therapy once daily at bedtime for a few days before increasing to twice daily 1
• Refractory cases: For persistent symptoms despite appropriate medical therapy, consider referral to an otolaryngologist to evaluate for structural abnormalities or rare causes like nasopharyngeal lesions 3
• Emerging treatments: For truly refractory cases, posterior nasal nerve ablation has shown efficacy for postnasal drip as a primary complaint in 72.5% of patients 4

Duration of Treatment

For chronic post nasal drip that responds to therapy:

• Continue intranasal corticosteroids for at least 3 months 1
• First-generation antihistamine/decongestant combinations should be continued for at least 3 weeks 1
• Topical decongestants should be limited to 5-7 days maximum 1, 2

Remember that post nasal drip can be a challenging condition to treat, and patients may require multiple medication adjustments before finding optimal symptom control.