What are the treatment options for post nasal drip?

Treatment Options for Post Nasal Drip

First-line therapy for post nasal drip should include a first-generation antihistamine plus decongestant combination, along with saline nasal irrigation and intranasal corticosteroids. 1

First-Line Treatment Options

Medication Therapy

• Antihistamine-Decongestant Combinations:

  • First-generation antihistamines (e.g., 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 for adequate response 1
  • Note: First-generation antihistamines may cause sedation and anticholinergic side effects

• Intranasal Corticosteroids:

  • Examples include fluticasone propionate nasal spray
  • May begin providing relief on first day of use but takes several days to reach full effectiveness 2
  • Should be continued for at least 3 months after symptoms resolve for chronic post nasal drip 1
  • Proper technique is important:
    • Shake bottle well
    • Look down by bending neck toward floor
    • Insert nozzle just inside nostril (right hand for left nostril, left hand for right nostril)
    • Aim toward outer wall to prevent irritation and bleeding
    • Do not sniff hard 3

• Saline Nasal Irrigation:

  • Provides beneficial effects by:
    • Improving mucous clearance
    • Enhancing ciliary activity
    • Disrupting and removing antigens, biofilms, and inflammatory mediators
    • Directly protecting sinonasal mucosa 3
  • Irrigation is more effective than saline spray for expelling secretions 3
  • Can be performed with isotonic or hypertonic solutions 3
  • Low-cost option, especially with homemade solutions 3

Short-Term Options

• Topical Decongestants:
  • Should be used for short-term only (maximum 5-7 days) to avoid rhinitis medicamentosa 1
  • When combined with intranasal corticosteroids, may provide better symptom relief without rebound swelling 3

Second-Line and Adjunctive Treatments

• Ipratropium Bromide Nasal Spray: Consider for rhinorrhea-predominant symptoms 1
• Leukotriene Receptor Antagonists: May be considered as additional treatment 1
• Adequate Hydration: Important for thinning mucus secretions 1

Treatment Approach Based on Underlying Cause

Post nasal drip can result from various conditions, requiring targeted approaches:

1. Allergic Rhinitis:

   • Intranasal corticosteroids + antihistamines
   • Consider allergen avoidance

2. Nonallergic Rhinitis:

   • Intranasal corticosteroids
   • Ipratropium bromide for rhinorrhea

3. Chronic Rhinosinusitis:

   • Saline irrigation
   • Intranasal corticosteroids
   • Consider antibiotics if bacterial infection suspected

4. Rhinitis Medicamentosa:

   • Discontinue offending topical decongestant
   • Intranasal corticosteroids

Monitoring and Follow-Up

• Evaluate response after 1-2 weeks of treatment
• If no improvement after one week, consider other diagnoses including sinusitis or GERD 2
• For persistent symptoms, consider referral to an otolaryngologist 1

Common Pitfalls and Caveats

1. Overuse of Decongestants: Limit topical decongestants to 5-7 days to prevent rebound congestion (rhinitis medicamentosa) 1

2. Inadequate Duration of Treatment: Intranasal corticosteroids require consistent use for 2-8 weeks before maximum benefit 1

3. Incorrect Nasal Spray Technique: Improper technique reduces medication delivery to target tissues 3

4. Confusing Saline Spray with Irrigation: Irrigation is more effective for expelling secretions than spray 3

5. Missing Serious Underlying Conditions: Consider referral if symptoms persist despite appropriate therapy, especially with warning signs like unilateral symptoms or bloody discharge 1

6. Side Effects Monitoring: Watch for sedation, urinary retention, hypertension, and tachycardia with antihistamine-decongestant combinations, particularly in elderly patients 1

Recent research suggests that chronic idiopathic post nasal drip may be a distinct entity, with approximately 71.6% of patients responding positively to first-generation antihistamine-decongestant medication 4, supporting the recommended first-line approach.