What is the treatment for post nasal drip?

Treatment for Post Nasal Drip

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

Treatment Algorithm Based on Underlying Cause

First-line treatments:

• For allergic rhinitis-related post nasal drip: nasal corticosteroids, antihistamines, and/or cromolyn 1
• For non-allergic rhinitis-related post nasal drip: first-generation antihistamine plus decongestant combination 2, 1
• Specific effective combinations include dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate, and azatadine maleate plus sustained-release pseudoephedrine 1

For post-viral upper respiratory infection:

• First-generation antihistamine/decongestant combinations have proven efficacy in both acute and chronic cough 1
• Newer generation antihistamines with or without pseudoephedrine are ineffective for acute cough in post-viral upper respiratory infection 1

For sinusitis-related post nasal drip:

• Acute bacterial sinusitis: antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae 2
• Intranasal corticosteroids to decrease inflammation 2
• Decongestants such as oxymetazoline hydrochloride (limited to 5 days to prevent rhinitis medicamentosa) 2

For vasomotor rhinitis:

• Azelastine nasal spray is FDA-approved for symptoms of vasomotor rhinitis, including post nasal drip in adults and children 12 years and older 3
• Ipratropium bromide nasal spray for patients who don't respond to antihistamine/decongestant combinations or have contraindications 1

Medication-Specific Guidance

Antihistamine/Decongestant Combinations:

• Most patients will see improvement in cough within days to 2 weeks of initiating therapy 1
• To minimize sedation from first-generation antihistamines, start with once-daily dosing at bedtime for a few days before increasing to twice-daily therapy 2
• Common side effects include dry mouth and transient dizziness 2
• Monitor for more serious side effects: insomnia, urinary retention, jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 2

Nasal Corticosteroids:

• For allergic rhinitis with post nasal drip, a 1-month trial is recommended 2
• Nasal corticosteroids are effective in reducing total symptom score in adults suffering from acute post-viral rhinosinusitis, though the effect is small 2
• For chronic rhinitis conditions, longer treatment courses may be necessary 2

Nasal Saline Irrigation:

• One small study found a larger effect of high volume versus low volume saline rinsing on purulent rhinorrhea and post nasal drip 2
• Although evidence quality is low, saline can be expected to be beneficial rather than harmful 2

For Refractory Cases:

• For chronic sinusitis that appears refractory to medical therapy with anatomic obstruction, endoscopic sinus surgery should be considered 2
• Posterior nasal nerve ablation has shown efficacy for patients with post nasal drip as their primary complaint who have failed medical therapy 4

Common Pitfalls and Caveats

• Newer-generation antihistamines are less effective for non-allergic causes of post nasal drip cough 1
• Diagnosis can be challenging as symptoms and clinical findings are not reliable discriminators 2
• Nasal decongestant sprays should not be used for more than 5 days to avoid rhinitis medicamentosa 2
• In rhinitis medicamentosa, the key to therapy is stopping or weaning off the offending agent 2
• Post nasal drip may sometimes not be caused by actual secretions draining from the nose into the pharynx, making diagnosis challenging 5
• Persistent, unexplainable post nasal drip or symptoms associated with warning signs of malignancy warrant referral to an otolaryngologist 5

Special Considerations

• For environmental irritant-induced rhinitis: avoidance of exposure, improved ventilation, filters, and in rare circumstances, personal protective devices 2
• For rhinitis of pregnancy: symptoms typically resolve postpartum; treatment options may be limited by pregnancy safety considerations 2
• For occupational rhinitis: analysis by an industrial engineer or hygienist may be required to identify the source 2