What are the treatment options for post nasal drip?

Treatment Options for Post Nasal Drip

First-line treatment for post nasal drip is a first-generation antihistamine-decongestant combination, followed by intranasal corticosteroids if symptoms persist. 1

First-Line Therapy

• First-generation antihistamine-decongestant combinations:
  • Expected to show improvement within days to 1-2 weeks
  • Complete resolution may take several weeks
  • Maximum recommended duration: 3 weeks
  • Use with caution in patients with glaucoma, prostatic hypertrophy, or hypertension
  • Common side effects: dry mouth, dizziness, sedation, urinary retention, tachycardia 1

Second-Line/Persistent Symptoms Management

• Intranasal corticosteroids (if partial response to first-line therapy):

  • Fluticasone propionate nasal spray: 1-2 sprays in each nostril once or twice daily
  • Initial trial: 1 month; may continue for up to 3 months if effective
  • Reduces inflammation and decreases mucus production 1, 2
  • Individualize dosage based on response:
    • Adults may start with 200 mcg once daily (two 50-mcg sprays in each nostril)
    • Alternative: 100 mcg twice daily (one 50-mcg spray in each nostril twice daily)
    • May reduce to 100 mcg/day for maintenance after 4-7 days 2

• Saline nasal irrigation:

  • Improves mucociliary clearance
  • High-volume irrigation more effective than low-volume for purulent rhinorrhea and post-nasal drip 1

• Additional options for partial response:

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

Treatment Algorithm

1. Start with first-generation antihistamine-decongestant combination for 1-2 weeks
2. Evaluate response after 3-5 days:
   • If improving, continue for up to 3 weeks
   • If minimal improvement after 10-14 days, change therapy
3. For partial response:
   • Add intranasal corticosteroid
   • Consider saline nasal irrigation
4. For persistent symptoms despite combined therapy:
   • Consider nasal anticholinergics or antihistamines
   • Consider leukotriene inhibitors
   • Evaluate for coexisting conditions (asthma, GERD)
5. For refractory cases:
   • ENT specialist consultation
   • Consider allergy testing
   • Evaluate environmental triggers 1

Special Considerations

• For allergic components: Prioritize antihistamines in the treatment plan 1
• For elderly patients: Monitor for dehydration and consider nutritional support 1
• For children under 6: First-generation antihistamine/decongestant combinations not recommended due to safety concerns 1

Non-Pharmacological Approaches

• Adequate hydration
• Warm facial packs
• Sleeping with head elevated
• Avoiding irritants (cigarette smoke, pollution, allergens) 1

Common Pitfalls to Avoid

• Overuse of antibiotics: Most cases of rhinosinusitis are viral, not bacterial
• Relying on mucus color: Color relates to neutrophils, not necessarily bacteria
• Premature discontinuation: Complete resolution may take several weeks to months
• Failure to identify underlying cause: Post nasal drip can result from various conditions including chronic rhinitis (22%), chronic sinusitis or nasal polyp (31%), allergic rhinitis (28%), adenoid vegetation (16%), and chronic nasopharyngitis (3%) 1, 3

For patients with severe, refractory post nasal drip that fails to respond to medical therapy, posterior nasal nerve ablation has shown promise as a surgical intervention, with 72.5% of patients reporting at least 30% improvement in symptoms 4.