How to manage symptoms of runny nose and cough with expectoration in a 70-year-old female, refractory to treatment with levocetirizine (antihistamine) 5mg and montelukast (leukotriene receptor antagonist) 10mg twice daily, ambroxol (mucolytic) 60mg twice daily, and guaiphenesin (expectorant) 100mg twice daily for 15 days?

Management of Persistent Rhinitis and Cough with Expectoration in an Elderly Patient

For a 70-year-old female with persistent runny nose and productive cough refractory to current treatment, the most effective next step is to add an intranasal corticosteroid spray such as fluticasone propionate at a dose of 100 mcg (one 50-mcg spray in each nostril) twice daily for 2-4 weeks.

Current Treatment Assessment

The patient has been on a regimen that includes:

• Levocetirizine 5mg twice daily (antihistamine)
• Montelukast 10mg twice daily (leukotriene receptor antagonist)
• Ambroxol 60mg twice daily (mucolytic)
• Guaifenesin 100mg twice daily (expectorant)

Despite 15 days of this therapy, symptoms persist, indicating treatment failure and the need for a different approach.

Recommended Treatment Algorithm

Step 1: Add Intranasal Corticosteroid

• Primary recommendation: Fluticasone propionate nasal spray 100 mcg (one spray in each nostril) twice daily 1
• Intranasal corticosteroids are the most effective medication for controlling both rhinorrhea and cough with expectoration when symptoms are refractory to antihistamines 2, 3
• Fluticasone has demonstrated efficacy in reducing total nasal symptom scores (TNSS) including rhinorrhea in clinical trials 1

Step 2: Consider Adding Intranasal Anticholinergic

• If rhinorrhea remains predominant after 1 week of intranasal corticosteroid therapy, add ipratropium bromide nasal spray 2, 3
• Intranasal anticholinergics effectively reduce rhinorrhea and can be combined with intranasal corticosteroids for increased efficacy without increased adverse effects 2

Step 3: Optimize Current Medication

• Adjust levocetirizine to once daily dosing (standard dosing) 2
• Adjust montelukast to once daily dosing (standard dosing) 2
• Continue ambroxol and guaifenesin if productive cough persists

Step 4: For Persistent Symptoms After 2 Weeks

• Consider a short course (5-7 days) of oral corticosteroids for very severe or intractable rhinitis 2
• Consider evaluation for underlying conditions such as sinusitis or non-allergic rhinitis with predominant rhinorrhea 2

Rationale for Recommendation

1. Intranasal corticosteroids are first-line therapy for refractory cases: Guidelines recommend intranasal corticosteroids for patients with rhinitis symptoms not responding to antihistamines 2, 3. They effectively reduce both nasal congestion and rhinorrhea associated with both allergic and non-allergic rhinitis.

2. Combination therapy effectiveness: The combination of intranasal corticosteroids with oral antihistamines and leukotriene antagonists has shown superior efficacy compared to monotherapy in persistent rhinitis 4, 5, 6.

3. Age-appropriate considerations: For elderly patients (70 years old), intranasal corticosteroids have a better safety profile compared to increasing doses of oral medications or adding first-generation antihistamines which can cause sedation and anticholinergic effects 3.

4. Addressing both upper and lower respiratory symptoms: Intranasal corticosteroids can improve both rhinitis and associated lower respiratory symptoms including cough with expectoration 2.

Important Clinical Considerations

• Monitor for local side effects: Examine the nasal septum periodically for mucosal erosions. Direct sprays away from the nasal septum to minimize irritation and bleeding 2.

• Correct technique is crucial: Proper administration technique significantly affects efficacy. The patient should be instructed to:

  • Gently blow nose before use
  • Shake container well
  • Tilt head slightly forward
  • Insert spray tip into nostril away from septum
  • Spray while breathing in gently

• Duration of therapy: Initial treatment should be for 2-4 weeks, with reassessment of symptoms. If symptoms improve, continue for maintenance 3, 1.

• Medication optimization: The current regimen uses twice-daily dosing for both levocetirizine and montelukast, which exceeds standard recommendations. Adjusting to standard once-daily dosing may improve compliance while maintaining efficacy 2.

• Elderly-specific concerns: In elderly patients, monitor for potential systemic effects of intranasal corticosteroids, though these are minimal at recommended doses 2.

When to Consider Specialist Referral

If symptoms persist despite 4 weeks of optimized therapy including intranasal corticosteroids, consider referral to an otolaryngologist or allergist to:

• Evaluate for structural abnormalities
• Consider nasal endoscopy to assess for nasal polyps
• Evaluate for chronic rhinosinusitis
• Consider allergy testing if not previously done 3