What are the treatment options for post nasal drip?

Treatment Options for Post Nasal Drip

First-line therapy for post nasal drip should be a first-generation antihistamine plus decongestant combination, as recommended by the American College of Chest Physicians. 1

Underlying Causes of Post Nasal Drip

Post nasal drip (PND), now more accurately termed Upper Airway Cough Syndrome (UACS), can result from various underlying conditions:

• Allergic rhinitis
• Perennial nonallergic rhinitis
• Bacterial sinusitis
• Rhinitis medicamentosa (rebound congestion from overuse of topical decongestants)
• Occupational rhinitis
• Rhinitis of pregnancy
• Physical or chemical irritants 2

Treatment Algorithm

First-line Treatment

• First-generation antihistamine/decongestant combinations:
  • Examples: dexbrompheniramine maleate (6 mg twice daily) or azatadine maleate (1 mg twice daily) plus sustained-release pseudoephedrine sulfate (120 mg twice daily) 1
  • Continue for at least 3 weeks 1
  • Note: First-generation antihistamines may cause sedation and anticholinergic effects, particularly in elderly patients 1

Second-line and Adjunctive Treatments

• Intranasal corticosteroids (e.g., fluticasone propionate):

  • Dosage: 100-200 mcg daily (1-2 sprays in each nostril once daily) 3
  • Continue for at least 3 months after symptoms resolve 1
  • Maximum effect may take several days to achieve 3

• Saline nasal irrigation:

  • Helps clear mucus and irritants 1
  • Can be used alongside other treatments

• Topical decongestants:

  • For short-term use only (maximum 5-7 days) 1
  • Caution: Longer use can lead to rhinitis medicamentosa 2

• Ipratropium bromide nasal spray:

  • Particularly effective for rhinorrhea-predominant symptoms 1

• Leukotriene receptor antagonists (e.g., montelukast):

  • May be considered as an additional treatment option 1, 4
  • Particularly helpful when combined with antihistamines for allergic causes 4

For Specific Underlying Causes

If Bacterial Sinusitis is Suspected:

• Antibiotic therapy effective against H. influenzae, anaerobes, and S. pneumoniae for 3 weeks 1
• Continue intranasal corticosteroids for 3 months after symptoms resolve 1

If Allergic Rhinitis is the Cause:

• Consider allergen avoidance measures
• Antihistamine/decongestant combinations are particularly effective 2, 1

If Rhinitis Medicamentosa is Present:

• Discontinue topical decongestants
• May require intranasal corticosteroids during withdrawal period 2

Special Considerations

For Elderly Patients:

• Start with lower doses of antihistamines 1
• Monitor for side effects such as sedation, urinary retention, hypertension, tachycardia, and increased intraocular pressure 1
• Ensure adequate hydration 1

For Refractory Cases:

• Consider referral to an otolaryngologist to evaluate for structural abnormalities or rare causes like nasopharyngeal lesions 1
• Posterior nasal nerve ablation may be considered for medically refractory cases, with 72.5% of patients reporting at least 30% improvement in PND symptoms in recent studies 5
• Consider presence of S. aureus nasal colonization, which may negatively impact treatment outcomes 6

Warning Signs for Referral:

• Unilateral symptoms
• Bloody discharge
• Progressive or persistent symptoms despite appropriate therapy
• Associated warning signs of malignancy 7

Treatment Duration

• First-generation antihistamine/decongestant combinations: at least 3 weeks 1
• Intranasal corticosteroids: continue for at least 3 months for chronic post nasal drip that responds to therapy 1
• Topical decongestants: limit to 5-7 days maximum 1

When post nasal drip fails to respond to initial therapy, reevaluate the diagnosis and consider alternative or additional treatments based on the suspected underlying cause.