What is the treatment for postnasal drip cough?

Treatment for Postnasal Drip Cough

First-generation antihistamine/decongestant combinations are the most effective first-line treatment for postnasal drip cough, with older-generation antihistamines being superior to newer non-sedating antihistamines due to their anticholinergic properties. 1

Treatment Algorithm Based on Underlying Cause

For All Types of Postnasal Drip Cough:

• Treatment options can be classified into: (1) avoidance of triggers, (2) medications to block or reduce inflammation and secretions, (3) treatment of infection, and (4) correction of structural alterations 1

For Allergic Rhinitis-Related Postnasal Drip:

• First-line therapy: Nasal corticosteroids (such as fluticasone propionate), antihistamines, and/or cromolyn 1

  • Fluticasone nasal spray: 200 mcg once daily (two 50-mcg sprays in each nostril) or 100 mcg twice daily 2

• Second-line options:

  • Oral leukotriene inhibitors have been shown to decrease symptoms of allergic rhinitis 1
  • Nonsedating antihistamines may be more effective for allergic rhinitis than for non-allergic rhinitis 1

For Non-Allergic Rhinitis-Related Postnasal Drip:

• First-line therapy: Older-generation (first-generation) antihistamine plus decongestant combination 1

  • Specific effective combinations include:
    • Dexbrompheniramine maleate (6 mg twice daily) plus sustained-release pseudoephedrine sulfate (120 mg twice daily) 1
    • Azatadine maleate (1 mg twice daily) plus sustained-release pseudoephedrine sulfate (120 mg twice daily) 1

• Alternative therapy: Ipratropium bromide nasal spray for patients who don't respond to antihistamine/decongestant combinations or have contraindications (glaucoma, symptomatic benign prostatic hypertrophy) 1

• For vasomotor rhinitis: Azelastine nasal spray (two sprays per nostril twice daily) has shown efficacy for symptoms including rhinorrhea, post-nasal drip, and nasal congestion 3

For Postviral Upper Respiratory Infection:

• First-generation antihistamine/decongestant combinations have proven efficacy in both acute and chronic cough 1
• Newer generation antihistamines (terfenadine, loratadine) with or without pseudoephedrine were found ineffective for acute cough in this condition 1

Important Clinical Considerations

• Timing of response: Most patients will see improvement in cough within days to 2 weeks of initiating therapy 1

• Managing side effects:

  • To minimize sedation from first-generation antihistamines, consider starting with once-daily dosing at bedtime for a few days before increasing to twice-daily therapy 1
  • Common side effects include dry mouth and transient dizziness 1
  • More serious side effects to monitor for include insomnia, urinary retention (especially in older men), jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 1

• Duration of treatment:

  • For intranasal corticosteroids in allergic rhinitis with postnasal drip, a 1-month trial is recommended 1
  • For chronic rhinitis conditions, longer treatment courses may be necessary 1

Alternative Approaches

• Oral gargling with normal saline: May be effective for patients with sensation of postnasal drip without cough, helping to dilute and remove mucus from the nasopharynx and oropharynx 4

• Posterior nasal nerve ablation: A newer surgical option that has shown efficacy for medically refractory postnasal drip, with 72.5% of patients reporting at least 30% improvement in symptoms 5

Common Pitfalls and Caveats

• Newer-generation (non-sedating) antihistamines are less effective for non-allergic causes of postnasal drip cough 1

• The diagnosis of postnasal drip syndrome can be challenging as symptoms and clinical findings are not reliable discriminators 1

• There is often poor correlation between endoscopic findings and symptoms of postnasal drip 4

• Postnasal drip cough may be related to airway sensory hypersensitivity rather than just irritation from nasal secretions 6

• Treatment should be directed at the specific underlying cause when identified rather than empiric therapy 1