Treatment Options for Post Nasal Drip
First-line treatment for post nasal drip includes saline nasal irrigation and intranasal corticosteroids, with short-term use of first-generation antihistamine/decongestant combinations for symptomatic relief in adults and children over 6 years of age. 1
First-Line Treatments
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 1
- Can be used safely in all age groups
- Available as isotonic or hypertonic solutions
Intranasal Corticosteroids
- Recommended as first-line therapy 1
- Options include fluticasone propionate nasal spray
- Dosing:
- Adults: 200 mcg daily (two 50-mcg sprays in each nostril once daily) or 100 mcg twice daily
- Children (4+ years): Start with 100 mcg daily (one spray in each nostril once daily)
- Increase to 200 mcg daily if inadequate response 2
- Onset of action may begin within 12 hours, but maximum effect may take several days 2
Second-Line Treatments
Antihistamine-Decongestant Combinations
- First-generation antihistamine/decongestant combinations for short-term use (maximum 3 weeks) 1
- Particularly effective for allergic causes of post nasal drip
- 71.6% of patients with chronic idiopathic post nasal drip respond positively to this treatment 3
- Cautions:
- Not recommended for children under 6 years due to safety concerns
- Monitor for side effects: sedation, urinary retention, hypertension, tachycardia
- Start with lower doses in elderly patients 1
Ipratropium Bromide Nasal Spray
- Consider for rhinorrhea-predominant symptoms 1
- Particularly effective for non-allergic causes of rhinitis
Leukotriene Receptor Antagonists
- Additional treatment option, especially for patients with concurrent asthma 1
Treatment Based on Underlying Cause
Allergic Rhinitis
- Non-sedating antihistamines and intranasal corticosteroids 1
- Consider allergen testing for targeted therapy
- Allergen avoidance measures when possible
Chronic Sinusitis
- Intranasal corticosteroids and saline irrigation as primary therapy
- Consider antibiotics if bacterial infection is suspected and symptoms persist >4 weeks 1
Chronic Rhinitis (Non-allergic)
- Ipratropium bromide nasal spray
- Intranasal corticosteroids
- Posterior nasal nerve ablation may be considered for refractory cases (72.5% of patients report ≥30% improvement in symptoms) 4
Treatment Algorithm
- Initial therapy: Saline nasal irrigation + intranasal corticosteroids for 2-4 weeks
- If inadequate response:
- Assess for specific cause (allergic vs. non-allergic)
- For allergic symptoms: Add non-sedating antihistamine
- For rhinorrhea-predominant symptoms: Add ipratropium bromide nasal spray
- For short-term relief: Consider first-generation antihistamine/decongestant (adults and children >6 years)
- If still inadequate response after 4 weeks:
- Consider referral to otolaryngologist, especially with warning signs like unilateral symptoms or bloody discharge
- Evaluate for underlying conditions: chronic sinusitis, GERD, allergic rhinitis
Important Considerations
- Topical decongestants should be limited to 5-7 days maximum to prevent rhinitis medicamentosa 1
- OTC cough and cold medications are not recommended for children under 6 years 1
- Monitor for symptom recurrence, which occurs in approximately 25.9% of patients 3
- Empiric treatment response is both diagnostic and therapeutic as there is no definitive test to confirm post nasal drip 1
Special Populations
Children
- First-line: Saline irrigation and intranasal corticosteroids at age-appropriate doses
- Avoid antihistamine-decongestant combinations in children under 6 years
- For children 4+ years: Start with 100 mcg intranasal corticosteroid daily 2
Elderly
- Start with lower doses of antihistamines and decongestants
- Consider anticholinergic burden of first-generation antihistamines
- Ensure adequate fluid intake and monitor for dehydration 1
Post nasal drip treatment should be tailored based on the underlying cause, with saline irrigation and intranasal corticosteroids forming the cornerstone of therapy for most patients.