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

Understanding Post Nasal Drip (Now Called Upper Airway Cough Syndrome)

• Post nasal drip (PND) is the drainage of secretions from the nose or paranasal sinuses into the pharynx, now preferably termed Upper Airway Cough Syndrome (UACS) 2
• UACS is the most common cause of chronic cough in adults 2
• Symptoms include sensation of drainage in the throat, throat clearing, nasal discharge, and cobblestone appearance of the oropharyngeal mucosa 2
• Some patients may have "silent" post nasal drip with no obvious symptoms yet respond to treatment 2

Treatment Algorithm Based on Underlying Cause

First-Line Treatments:

• For allergic rhinitis-related post nasal drip:

  • Nasal corticosteroids (e.g., fluticasone, triamcinolone, budesonide, mometasone) 1, 3
  • Second-generation antihistamines (e.g., cetirizine, fexofenadine, loratadine) 1, 3
  • Allergen avoidance measures 3

• For non-allergic rhinitis-related post nasal drip:

  • First-generation antihistamine plus decongestant combinations 1
  • Specific effective combinations include:
    • Dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate 1
    • Azatadine maleate plus sustained-release pseudoephedrine sulfate 1

• For all types of post nasal drip:

  • Nasal saline irrigation to improve mucus clearance, enhance ciliary activity, and remove inflammatory mediators 4
  • High-volume saline rinsing is more effective than low-volume for purulent rhinorrhea and post-nasal drip 4

Second-Line Treatments:

• Ipratropium bromide nasal spray for patients who don't respond to antihistamine/decongestant combinations or have contraindications 1
• For chronic rhinosinusitis with post nasal drip, long-term low-dose macrolides may be effective 5
• Intranasal corticosteroids in combination with antihistamines for moderate to severe cases 1, 3

Treatment Duration and Expected Response

• Most patients will see improvement in cough within days to 2 weeks of initiating therapy 1
• For intranasal corticosteroids in allergic rhinitis with post nasal drip, a 1-month trial is recommended 1
• For chronic rhinitis conditions, longer treatment courses may be necessary 1

Important Clinical Considerations

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

Common Pitfalls and Caveats

• Newer-generation antihistamines are less effective for non-allergic causes of post nasal drip cough 1
• The diagnosis of post nasal drip syndrome can be challenging as symptoms and clinical findings are not reliable discriminators 1
• Failure to consider "silent" UACS as a causative factor for chronic cough can lead to missed diagnoses 2
• Post nasal drip can sometimes be confused with other conditions like gastroesophageal reflux disease (GERD) 2, 6
• Some patients may have hard-to-recognize post nasal drip that requires careful examination to identify underlying causes such as latent chronic sinusitis, nasopharyngeal lesions, or polyps 5

Practical Implementation Tips

• Different delivery methods for nasal saline irrigation include pot, pulsatile irrigation, atomizer, bulb/syringe, squeeze bottle, and low-pressure irrigation (neti pot) 4
• For patients with persistent symptoms despite first-line therapy, consider combination therapy with intranasal corticosteroids and antihistamines 1, 3
• Regular use of nasal saline irrigation is recommended as both a sole treatment and as an adjunct to other therapies 4