What are the treatment options for post nasal drip?

Treatment of Post Nasal Drip

First-line treatment for post nasal drip should be intranasal corticosteroids followed by adding a first-generation antihistamine/decongestant combination if symptoms persist. 1

Understanding Post Nasal Drip

Post nasal drip (PND) refers to the sensation of secretions draining into the posterior pharynx from the nose or sinuses, often accompanied by nasal stuffiness and sinusitis 2. It's a common clinical complaint that can significantly impact quality of life through persistent throat clearing, cough, and discomfort.

Treatment Algorithm

Step 1: Identify Underlying Cause

• Chronic rhinitis (22% of cases) 3
• Chronic sinusitis or nasal polyps (31% of cases) 3
• Allergic rhinitis (28% of cases) 3
• Adenoid vegetation (16% of cases) 3
• Chronic nasopharyngitis (3% of cases) 3
• Gastroesophageal reflux disease (GORD) 2
• Rhinitis medicamentosa (from overuse of topical decongestants) 2

Step 2: First-Line Treatment

• Intranasal corticosteroids (e.g., fluticasone propionate nasal spray)
  • Dosage: 100 mcg (1 spray in each nostril) once or twice daily 4
  • Duration: Minimum 2-8 weeks for adequate effect 1
  • Mechanism: Reduces inflammation and nasal secretions

Step 3: If Inadequate Response After 2-4 Weeks

• Add first-generation antihistamine plus decongestant combination 1
  • Options: dexbrompheniramine maleate (6 mg twice daily) or azatadine maleate (1 mg twice daily) plus sustained-release pseudoephedrine sulfate (120 mg twice daily) 1
  • Duration: Minimum 3 weeks 1
  • Tip: Start once daily at bedtime for a few days before increasing to twice daily to manage sedation 1

Step 4: Additional Therapies Based on Specific Causes

• For allergic rhinitis:

  • Continue intranasal corticosteroids 2
  • Consider leukotriene receptor antagonists 1

• For rhinorrhea-predominant symptoms:

  • Add ipratropium bromide nasal spray 1

• For nasal congestion:

  • Short-term topical decongestants (maximum 5-7 days to prevent rhinitis medicamentosa) 1

• For suspected bacterial sinusitis:

  • Antibiotics effective against H. influenzae, anaerobes, and S. pneumoniae for minimum 3 weeks 2
  • Continue intranasal corticosteroids for 3 months after symptoms resolve 2

• For GORD-related post nasal drip:

  • Proton pump inhibitors (PPIs) such as omeprazole 20–40 mg twice daily before meals for at least 8 weeks 2
  • Consider prokinetic agents such as metoclopramide 10 mg three times daily if needed 2

• For all patients:

  • Saline nasal irrigation for symptom relief 1

Important Considerations

Duration of Treatment

• Continue intranasal corticosteroids for at least 3 months for chronic post nasal drip that responds to therapy 1
• Maximum effect of intranasal corticosteroids may take several days 4

Monitoring for Side Effects

• Watch for sedation with first-generation antihistamines 2
• Monitor for insomnia, urinary retention (especially in older men), jitteriness, tachycardia, hypertension, and increased intraocular pressure when using decongestants 2

When to Refer

• If symptoms persist despite adequate treatment for 3 months
• If warning signs are present (unilateral symptoms, bleeding, severe pain)
• To evaluate for structural abnormalities or rare causes like nasopharyngeal lesions 5

Pitfalls and Caveats

• Newer generation (non-sedating) antihistamines are less effective for non-allergic causes of post nasal drip 1
• Topical decongestants should never be used for more than 7 days to prevent rhinitis medicamentosa 1
• The sensation of PND may not always be due to actual secretions but could be related to mucosal inflammation or sensory dysfunction 6, 7
• Some patients may require individualized treatment as PND can have multiple contributing factors 8

By following this treatment algorithm, most patients with post nasal drip should experience significant symptom improvement, with studies showing cure rates of up to 82% with appropriate targeted therapy 3.