What is the medical management of postnasal drip?

Medical Management of Postnasal Drip

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

Understanding Postnasal Drip

• Postnasal 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, 1
• 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" PND with no obvious symptoms yet still respond to treatment 1

Treatment Algorithm Based on Underlying Cause

First-line Treatments

• For non-allergic rhinitis-related postnasal drip: first-generation antihistamine plus decongestant combination 2, 1
• For allergic rhinitis-related postnasal drip: nasal corticosteroids, antihistamines, and/or cromolyn 1
• Effective first-generation antihistamine/decongestant combinations include dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate, and azatadine maleate plus sustained-release pseudoephedrine sulfate 1
• A minimum of 3 weeks of treatment with these medications is recommended for chronic cases 2

Nasal Corticosteroids

• Intranasal corticosteroids are effective for allergic rhinitis with postnasal drip and require a 1-month trial 2, 1
• Fluticasone propionate nasal spray has demonstrated efficacy in reducing nasal symptoms including postnasal drip 3
• Adult dosing: 200 mcg once daily (two 50-mcg sprays in each nostril) or 100 mcg twice daily 3
• Pediatric dosing (4 years and older): Start with 100 mcg (1 spray in each nostril once daily) 3

Alternative Treatments

• Ipratropium bromide nasal spray is an effective alternative for patients who don't respond to antihistamine/decongestant combinations or have contraindications 1
• For rhinitis due to physical or chemical irritants, avoidance of exposure, improved ventilation, filters, and personal protective devices are effective 2
• For rhinitis medicamentosa, the key is stopping or weaning off the offending agent 2

Treatment for Specific Conditions

• For acute bacterial sinusitis: antibiotics, intranasal corticosteroids, and decongestants 2
• For chronic sinusitis: minimum 3 weeks of antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae; 3 weeks of oral antihistamine/decongestant; and 5 days of nasal decongestant 2
• When cough disappears with therapy for chronic sinusitis, intranasal corticosteroids should be continued for 3 months 2

Clinical Considerations and Monitoring

Expected Response

• Most patients will see improvement in cough within days to 2 weeks of initiating therapy 1
• To minimize sedation from first-generation antihistamines, consider starting with once-daily dosing at bedtime before increasing to twice-daily therapy 1

Side Effects to Monitor

• Common side effects of first-generation antihistamines: dry mouth and transient dizziness 1
• More serious side effects: insomnia, urinary retention, jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 1

Treatment Duration

• For allergic rhinitis with postnasal drip: 1-month trial of intranasal corticosteroids 2, 1
• For chronic rhinitis conditions: longer treatment courses may be necessary 1
• For chronic sinusitis: minimum 3 weeks of treatment followed by 3 months of intranasal corticosteroids 2

Common Pitfalls and Caveats

• Newer-generation 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 2
• Some patients with UACS-induced cough (approximately 20%) are unaware of either the presence of PND or its link to their cough 2
• Failure to consider "silent" UACS as a causative factor for chronic cough can lead to missed diagnoses 1
• Endoscopic sinus surgery should be considered only for patients with documented chronic sinus infection refractory to medical therapy and with anatomic obstruction 2
• Post nasal drip can sometimes be confused with other conditions like gastroesophageal reflux disease (GERD) 1