Treatment Options for Post Nasal Drip
Saline nasal irrigation and intranasal corticosteroids are the first-line treatments for post nasal drip, 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 Treatment Options
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
- The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS 2020) considers nasal saline irrigation an important aspect of CRS management 2
- Can be delivered via various methods (spray, nebulization, or nasal douching) 2
Intranasal Corticosteroids
- Recommended as first-line treatment along with saline irrigation 1
- Examples include fluticasone propionate 3
- Fluticasone propionate nasal spray has been shown to effectively reduce total nasal symptom scores, including postnasal drip 3
- Dosing:
- Adults: 200 mcg once daily (two 50-mcg sprays in each nostril) or 100 mcg twice daily
- Children (4 years and older): Start with 100 mcg (1 spray in each nostril once daily) 3
Second-Line Treatment Options
Antihistamine-Decongestant Combinations
- First-generation antihistamine/decongestant combinations for short-term use (maximum 3 weeks) 1
- Only recommended for adults and children over 6 years of age 1
- 71.6% of patients with chronic idiopathic postnasal drip respond positively to first-generation antihistamine-decongestant medication 4
- Caution: Topical decongestants should be limited to 5-7 days maximum to prevent rhinitis medicamentosa 1
Nasal Decongestants
- May be temporarily added to intranasal corticosteroids when the nose is very blocked 2
- One small study showed a significantly better effect of oxymetazoline combined with mometasone furoate nasal spray than mometasone alone without inducing rebound swelling 2
- EPOS 2020 suggests in general not to use nasal decongestants in chronic rhinosinusitis 2
Additional Options
- Ipratropium bromide nasal spray for rhinorrhea-predominant symptoms 1
- Leukotriene receptor antagonists as an additional treatment option 1
- Non-sedating antihistamines if allergic rhinitis is suspected 1
Treatment Algorithm Based on Underlying Cause
For all patients with post nasal drip:
- Start with saline nasal irrigation and intranasal corticosteroids 1
If symptoms persist, identify potential causes:
Targeted treatment based on cause:
- Allergic component: Add non-sedating antihistamines 1
- Significant nasal congestion: Consider short-term (5-7 days) nasal decongestant 2, 1
- Rhinorrhea-predominant: Consider ipratropium bromide nasal spray 1
- Persistent symptoms: Consider first-generation antihistamine/decongestant combinations (short-term use only) 1, 4
Special Considerations
Children
- First-generation antihistamine/decongestant combinations not recommended for children under 6 years 1
- Over-the-counter cough and cold medications not recommended for children under 6 years 1
- Children (4 years and older): Start with lower dose of intranasal corticosteroids (100 mcg daily) 3
Warning Signs Requiring Further Evaluation
- Unilateral symptoms
- Bloody discharge
- Persistent symptoms despite appropriate treatment for 4 weeks 1
- Consider referral to an otolaryngologist if symptoms persist 1, 6
Treatment Monitoring
- Empiric treatment response is both diagnostic and therapeutic for post nasal drip 1
- Monitor for side effects of medications and adjust accordingly 1
- If symptoms persist despite treatment, consider further investigations 1
Post nasal drip can significantly impact quality of life, but with the appropriate treatment algorithm focusing on saline irrigation and intranasal corticosteroids as first-line therapy, most patients can achieve symptom relief.