What is the treatment for postnasal drip?

Treatment for Postnasal Drip

First-generation antihistamine/decongestant combinations are the most effective first-line treatment for postnasal drip, with treatment tailored to the underlying cause. 1

Treatment Based on Underlying Cause

Allergic Rhinitis-Related Postnasal Drip

• First-line therapy includes nasal corticosteroids, antihistamines, and/or cromolyn 1
• Nasal corticosteroids require a 1-month trial for effectiveness evaluation 2
• Oral leukotriene inhibitors can decrease symptoms of allergic rhinitis 1
• Nonsedating antihistamines are more effective for allergic rhinitis than for non-allergic rhinitis 1
• Fluticasone propionate nasal spray (100-200 mcg daily) has demonstrated efficacy in reducing nasal symptoms including postnasal drip 3

Non-Allergic Rhinitis-Related Postnasal Drip

• First-line therapy is a first-generation antihistamine plus decongestant combination 1, 2
• Effective combinations include:
  • Dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate 2
  • Azatadine maleate plus sustained-release pseudoephedrine sulfate 2
• Ipratropium bromide nasal spray is an effective alternative for patients who don't respond to antihistamine/decongestant combinations or have contraindications 2

Sinusitis-Related Postnasal Drip

• For acute bacterial sinusitis: antibiotics, intranasal corticosteroids, and decongestants 4
• 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, followed by 3 months of intranasal corticosteroids 4, 2
• Hypertonic saline nasal wash (3.5%) has shown significant improvement in postnasal drip symptoms and radiological findings in pediatric chronic sinusitis 5

Rhinitis Due to Physical or Chemical Irritants

• Avoidance of exposure, improved ventilation, filters, and personal protective devices when necessary 4, 2

Rhinitis Medicamentosa

• Key treatment is stopping or weaning off the offending agent (typically topical decongestants) 4
• Can be done one nostril at a time to ease the process 4
• Antihistamine/decongestant combinations or nasal corticosteroids may help manage symptoms during withdrawal 4

Treatment Duration and Monitoring

• Most patients will see improvement in cough within days to 2 weeks of initiating therapy 1, 2
• For chronic conditions, longer treatment courses are necessary:
  • Allergic rhinitis with postnasal drip: minimum 1-month trial of intranasal corticosteroids 2
  • Chronic sinusitis: minimum 3 weeks of treatment followed by 3 months of intranasal corticosteroids 2
• To minimize sedation from first-generation antihistamines, start with once-daily dosing at bedtime for a few days before increasing to twice-daily therapy 4, 2

Side Effects to Monitor

• Common side effects of first-generation antihistamines include dry mouth and transient dizziness 4
• More serious side effects to watch for include:
  • Insomnia, urinary retention (especially in older men) 4
  • Jitteriness, tachycardia, worsening hypertension 4
  • Increased intraocular pressure in glaucoma patients 4

Common Pitfalls and Considerations

• Newer-generation antihistamines are less effective for non-allergic causes of postnasal drip cough 1, 2
• Some patients (approximately 20%) have "silent" postnasal drip with no obvious symptoms yet still respond to treatment 2
• Failure to consider "silent" postnasal drip as a cause for chronic cough can lead to missed diagnoses 2
• Postnasal drip can sometimes be confused with other conditions like gastroesophageal reflux disease 2
• Recent research suggests that chronic idiopathic postnasal drip may be a distinct entity, with 71.6% of patients responding positively to first-generation antihistamine-decongestant medication 6
• Endoscopic sinus surgery should be considered only for patients with documented chronic sinus infection refractory to medical therapy and with anatomic obstruction 2