What is the treatment for post nasal drip cough?

Treatment of Post Nasal Drip Cough

First-generation antihistamine-decongestant combinations are the recommended first-line therapy for post nasal drip cough (upper airway cough syndrome), followed by intranasal corticosteroids if symptoms persist. 1

First-Line Treatment

• First-generation antihistamine-decongestant combination:
  • Examples: dexbrompheniramine maleate plus sustained-release pseudoephedrine
  • Duration: Short-term use (maximum 3 weeks)
  • Expected response: Some improvement within days to 1-2 weeks; complete resolution may take several weeks
  • Cautions: May cause sedation, dry mouth, urinary retention; use with caution in patients with glaucoma, prostatic hypertrophy, or hypertension 1

Second-Line/Add-on Therapy for Persistent Symptoms

• Intranasal corticosteroids (if partial response to antihistamine-decongestant therapy):

  • Example: Fluticasone propionate nasal spray
  • Dosage: 1-2 sprays in each nostril once or twice daily
  • Duration: Initial 1-month trial; may continue for up to 3 months if effective 1, 2
  • Mechanism: Reduces inflammation in nasal passages, decreasing mucus production 1

• Additional options for partial responders:

  • Nasal anticholinergic agents (e.g., ipratropium bromide) - particularly for rhinorrhea-predominant symptoms 1
  • Nasal antihistamines 1
  • Leukotriene receptor antagonists as adjunctive therapy 1

Non-Pharmacological Approaches

• Adequate hydration
• Warm facial packs
• Sleeping with head elevated
• Avoiding irritants (cigarette smoke, pollution, allergens)
• Saline nasal irrigation to improve mucociliary clearance 1

Treatment Algorithm

1. Start with first-generation antihistamine-decongestant combination
2. Evaluate response after 3-5 days
3. If minimal improvement after 10-14 days, consider changing therapy
4. For partial response:
   • Continue treatment for another 10-14 days
   • Consider adding intranasal corticosteroids
5. If symptoms persist despite appropriate treatment:
   • Reassess diagnosis
   • Consider other causes of chronic cough (asthma, GERD)
   • Consider ENT specialist consultation

Special Considerations

• Allergic components: Antihistamines should play a more prominent role in treatment 1
• Suspected bacterial infection: Consider antibiotics (e.g., amoxicillin 500 mg twice daily for 10-14 days), but use judiciously as most cases are viral 1
• Refractory cases: May require ENT specialist consultation, serum Ig level measurement, allergy testing, and evaluation of environmental triggers 1
• Coexisting conditions: UACS often coexists with asthma and GERD; all causes must be treated for cough resolution 1

Common Pitfalls to Avoid

• Overuse of antibiotics: Most cases of rhinosinusitis are viral, not bacterial. Only 0.5% to 2.0% have bacterial etiology 1
• Relying on mucus color: The color of mucus relates to the presence of neutrophils, not bacteria 1
• Premature discontinuation: Complete resolution may take several weeks to months 1
• Overlooking coexisting conditions: UACS, asthma, and GERD account for 90% of chronic cough cases 1
• Safety in children: First-generation antihistamine/decongestant combinations are not recommended for children under 6 years due to safety concerns 1

Individualization of Treatment

For adult patients, treatment can be initiated with fluticasone propionate 200 mcg once daily (two 50-mcg sprays in each nostril once daily) or 100 mcg twice daily (one 50-mcg spray in each nostril twice daily). After 4-7 days, patients who have responded may be maintained on 100 mcg/day (1 spray in each nostril once daily) 2.

For pediatric patients (4 years and older), start with 100 mcg (1 spray in each nostril once daily) and reserve 200 mcg for those not adequately responding to 100 mcg daily 2.