How to treat post nasal drip?

Treatment of Post Nasal Drip

First-generation antihistamine/decongestant combinations are the most effective first-line treatment for post nasal drip, with a minimum of 3 weeks of treatment recommended for chronic cases. 1, 2

Understanding Post Nasal Drip

• Post nasal drip (PND) is now preferably termed Upper Airway Cough Syndrome (UACS), which is the most common cause of chronic cough in adults 1
• Symptoms include sensation of drainage in the throat, throat clearing, nasal discharge, and cobblestone appearance of the oropharyngeal mucosa 1
• 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 PND: First-generation antihistamine plus decongestant combination 1, 2

  • Effective combinations include dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate, and azatadine maleate plus sustained-release pseudoephedrine sulfate 1
  • Minimum of 3 weeks of treatment recommended for chronic cases 1

• For allergic rhinitis-related PND: 1

  • Nasal corticosteroids (e.g., fluticasone propionate) 3
  • Antihistamines (first-generation more effective than newer non-sedating types) 2
  • Leukotriene inhibitors can decrease symptoms of allergic rhinitis 2

Alternative and Adjunctive Treatments

• Ipratropium bromide nasal spray is effective for patients who don't respond to antihistamine/decongestant combinations or have contraindications 1, 2
• For rhinitis due to physical or chemical irritants: avoidance of exposure, improved ventilation, filters, and personal protective devices 4, 1
• Azelastine nasal spray has shown efficacy for both allergic and vasomotor rhinitis, particularly for symptoms including post nasal drip 5, 6
• Oral gargling with normal saline may be helpful for some patients with PND without cough 7

Treatment for Specific Conditions

• For acute bacterial sinusitis: 4

  • Antibiotics effective against S. pneumoniae and H. influenzae
  • Intranasal corticosteroids
  • Decongestants (e.g., oxymetazoline hydrochloride)

• For chronic sinusitis: 4, 1

  • Minimum 3 weeks of antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae
  • 3 weeks of oral antihistamine/decongestant
  • 5 days of nasal decongestant
  • Followed by 3 months of intranasal corticosteroids

• For rhinitis medicamentosa (rebound congestion from overuse of decongestant nasal sprays): 4

  • Discontinuation of the offending agent (can be done one nostril at a time)
  • Antihistamine/decongestant or nasal corticosteroids may help during weaning

Administration and Dosing Considerations

• To minimize sedation from first-generation antihistamines, start with once-daily dosing at bedtime before increasing to twice-daily therapy 4, 1
• Most patients will see improvement in cough within days to 2 weeks of initiating therapy 2
• For intranasal corticosteroids in allergic rhinitis with PND, a 1-month trial is recommended 1
• Fluticasone propionate nasal spray has shown efficacy for nasal symptoms including post nasal drip at doses of 100-200 mcg daily 3

Side Effects to Monitor

• Common side effects of first-generation antihistamines include dry mouth and transient dizziness 4, 1
• More serious side effects include insomnia, urinary retention (especially in older men), jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 4, 1
• Bitter taste is the most common side effect of azelastine nasal spray but can be minimized with correct dosing technique 6

Common Pitfalls and Caveats

• Newer-generation antihistamines are less effective for non-allergic causes of post nasal drip cough 1, 2
• Some patients with UACS-induced cough (approximately 20%) are unaware of either the presence of PND or its link to their cough 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
• For patients with difficult-to-recognize PND, careful examination may reveal underlying causes such as latent chronic sinusitis, nasopharyngeal lesions, or polyps around the sphenoid ostium 8
• Recent research suggests that PND-related cough may be related to airway sensory hypersensitivity rather than actual irritation from inflamed nasal secretions 9
• For patients with medically refractory PND, posterior nasal nerve ablation may be an effective treatment option 10