What is the most appropriate initial treatment for a non-smoker with a chronic nonproductive cough, clear rhinorrhea, and a sensation of needing to clear their throat, but no heartburn and a normal chest X-ray (CXR)?

Management of Chronic Nonproductive Cough with Clear Rhinorrhea

The most appropriate initial treatment for a non-smoker with chronic nonproductive cough, clear rhinorrhea, and throat clearing sensation is an oral antihistamine plus decongestant combination.

Clinical Presentation Analysis

The patient presents with:

• Chronic nonproductive cough
• Clear rhinorrhea
• Sensation of having to clear throat
• No worsening with exercise, night, or cold air
• No heartburn symptoms
• Normal chest X-ray
• Non-smoker

This clinical picture strongly suggests Upper Airway Cough Syndrome (UACS), previously known as postnasal drip syndrome, as the most likely diagnosis.

Diagnostic Reasoning

The combination of chronic cough with clear rhinorrhea and throat clearing without other concerning symptoms points to UACS as the primary diagnosis. The American College of Chest Physicians (ACCP) guidelines recommend a systematic approach to chronic cough that begins with addressing the most common causes:

1. UACS (most common cause)
2. Asthma
3. Non-asthmatic eosinophilic bronchitis
4. Gastroesophageal reflux disease (GERD)

In this case:

• The presence of clear rhinorrhea strongly suggests UACS 1, 2
• Normal CXR rules out significant pulmonary pathology
• Absence of heartburn makes GERD less likely as initial diagnosis
• No triggers like exercise or cold air make asthma less likely

Treatment Recommendation

According to the ACCP evidence-based clinical practice guidelines, first-generation antihistamine/decongestant combinations are the recommended initial treatment for UACS 1, 2. These guidelines specifically state:

"Treatment with A/D preparations is a time-tested and often effective approach to treating allergic rhinitis... The combination mitigates some of the effects of mast-cell degranulation via the antihistaminic effect, and causes vasoconstriction that limits the secretory response to inflammatory cytokines." 1

The 2025 Cough Management Guidelines also support this approach, recommending "first-generation antihistamine/decongestant combination for 2-4 weeks, such as brompheniramine with sustained-release pseudoephedrine" for UACS 2.

Treatment Algorithm

1. First-line therapy: Oral antihistamine plus decongestant combination for 2-4 weeks

   • Preferred options include dexbrompheniramine maleate (6 mg bid) or azatadine maleate (1 mg bid) plus sustained-release pseudoephedrine sulfate (120 mg bid) 1
   • First-generation antihistamines are preferred over newer generation antihistamines for non-allergic UACS due to their anticholinergic properties 1

2. If inadequate response after 2-4 weeks:

   • Consider adding ipratropium bromide nasal spray 1
   • Evaluate for other causes such as asthma (trial of inhaled corticosteroids) 1
   • Consider GERD evaluation (trial of proton pump inhibitor) 1

3. If still unresponsive:

   • Consider non-asthmatic eosinophilic bronchitis 1
   • Evaluate for unexplained chronic cough 1

Important Considerations

• First-generation vs. newer antihistamines: First-generation antihistamines are more effective for non-allergic UACS due to their anticholinergic properties 1
• Duration of therapy: Improvement typically occurs within days to 2 weeks 1
• Common pitfalls:
  • Using newer generation antihistamines alone, which have been shown to be ineffective in treating cough associated with non-allergic rhinitis 1
  • Inadequate duration of therapy (should be at least 2-4 weeks) 2
  • Treating only one cause when multiple etiologies may be contributing 2

Conclusion

Based on the clinical presentation and the strongest evidence from the ACCP guidelines, an oral antihistamine plus decongestant (Option D) is the most appropriate initial treatment for this patient with chronic nonproductive cough, clear rhinorrhea, and throat clearing sensation.