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 a minimum treatment duration of 3 weeks for chronic cases. 1

Treatment Based on Underlying Cause

Non-allergic Rhinitis-Related Post Nasal Drip

• First-line therapy is a first-generation antihistamine plus decongestant combination 2, 1
• Effective combinations include dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate, and azatadine maleate plus sustained-release pseudoephedrine sulfate 1
• Minimum treatment duration of 3 weeks is recommended for chronic cases 2, 3
• First-generation antihistamines are superior to newer non-sedating antihistamines due to their anticholinergic properties 1

Allergic Rhinitis-Related Post Nasal Drip

• First-line options include nasal corticosteroids, antihistamines, and/or cromolyn 2, 1
• Intranasal corticosteroids like fluticasone require a 1-month trial 3, 4
• Leukotriene inhibitors like montelukast have been shown to decrease symptoms of allergic rhinitis 2, 5
• Nonsedating antihistamines may be more effective for allergic rhinitis than for non-allergic rhinitis 2

Alternative Treatments

• Ipratropium bromide nasal spray is effective for patients who don't respond to antihistamine/decongestant combinations or have contraindications 1, 6
• For rhinitis due to physical or chemical irritants, avoidance of exposure, improved ventilation, filters, and personal protective devices are effective 2

Treatment for Specific Conditions

Acute Bacterial Sinusitis

• Treatment options include antibiotics, intranasal corticosteroids, and decongestants 2
• Consider holding antibiotics for 1 week as acute sinusitis is often viral 2

Chronic Sinusitis

• Recommended regimen: 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
• Follow with 3 months of intranasal corticosteroids when cough disappears 2
• Consider endoscopic sinus surgery only for patients with documented chronic sinus infection refractory to medical therapy and with anatomic obstruction 3

Rhinitis Medicamentosa

• Key treatment is stopping or weaning off the offending agent (typically topical α-agonists like oxymetazoline) 2
• Consider weaning one nostril at a time 2

Clinical Considerations and Monitoring

Expected Response

• Most patients will see improvement in cough within days to 2 weeks of initiating therapy 1
• In a recent study, 71.6% of patients with chronic idiopathic post nasal drip responded positively to first-generation antihistamine-decongestant medication 7

Managing Side Effects

• 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
• More serious side effects to monitor: insomnia, urinary retention, jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 2, 1

Common Pitfalls and Caveats

• Newer-generation antihistamines are less effective for non-allergic causes of post nasal drip cough 1
• Some patients (approximately 20%) have "silent" post nasal drip with no obvious symptoms yet still respond to treatment 1, 3
• Post nasal drip can sometimes be confused with other conditions like gastroesophageal reflux disease 3
• Approximately 25.9% of patients may experience symptom recurrence after initial improvement, particularly those with nasal stiffness or persistent symptoms 7
• For patients with refractory post nasal drip, posterior nasal nerve ablation has shown promising results with 72.5% of patients reporting at least 30% improvement in symptoms 8