What is the treatment for postnasal drip?

Treatment of Postnasal Drip

For non-allergic postnasal drip, first-generation antihistamine/decongestant combinations (such as dexbrompheniramine plus sustained-release pseudoephedrine) are the most effective first-line treatment, while allergic causes respond best to intranasal corticosteroids. 1, 2

Treatment Algorithm Based on Underlying Cause

Non-Allergic Rhinitis (Most Common)

• Start with first-generation antihistamine plus decongestant combination as recommended by the American College of Chest Physicians 1, 2
• Specific effective combinations include:
  • Dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate 1
  • Azatadine maleate plus sustained-release pseudoephedrine sulfate 1
• Minimum treatment duration: 3 weeks for chronic cases 2
• These older antihistamines are superior to newer non-sedating antihistamines due to their anticholinergic properties 1

Alternative if first-line fails or contraindicated:

• Ipratropium bromide nasal spray is an effective second-line option 1, 2

Allergic Rhinitis

• Intranasal corticosteroids are the most effective monotherapy and should be first-line 2
• Require a 1-month trial for adequate assessment 1, 2, 3
• Additional options include oral antihistamines, cromolyn, or leukotriene inhibitors 1
• Fluticasone propionate nasal spray 200 mcg daily (two 50-mcg sprays per nostril once daily) demonstrates significant symptom reduction 3

Chronic Sinusitis

• Minimum 3 weeks of antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae 2
• 3 weeks of oral antihistamine/decongestant combination 2
• 5 days of nasal decongestant (avoid longer use due to rhinitis medicamentosa risk) 2
• Followed by 3 months of intranasal corticosteroids 2

Irritant-Related Rhinitis

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

Dosing Strategy to Minimize Side Effects

To reduce sedation from first-generation antihistamines:

• Start with once-daily dosing at bedtime for a few days 1
• Then increase to twice-daily therapy as tolerated 1

Expected Timeline and Monitoring

Response timeline:

• Most patients improve within days to 2 weeks of initiating therapy 1
• For intranasal corticosteroids in allergic rhinitis, symptom reduction may begin within 12 hours but maximum effect takes several days 3

Common side effects to monitor:

• Dry mouth and transient dizziness are common with first-generation antihistamines 1
• More serious effects include insomnia, urinary retention, jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 1, 2
• Decongestants can cause insomnia, irritability, palpitations, and hypertension 2

Critical Pitfalls to Avoid

Medication selection errors:

• Newer-generation antihistamines are significantly less effective for non-allergic postnasal drip 1, 2
• Never use topical decongestants for more than 3-5 days due to rhinitis medicamentosa risk 2

Diagnostic considerations:

• Approximately 20% of patients have "silent" postnasal drip with no obvious symptoms yet respond to treatment 1, 2
• Failure to consider silent postnasal drip leads to missed diagnoses 2
• Symptoms and clinical findings are not reliable discriminators, making diagnosis challenging 1, 2

Treatment duration:

• For chronic conditions, longer treatment courses beyond the initial 2-week assessment may be necessary 1
• A recent 2024 study found 71.6% of chronic idiopathic postnasal drip patients responded to first-generation antihistamine-decongestant therapy, though 25.9% experienced symptom recurrence 4

Surgical considerations:

• Endoscopic sinus surgery should only be considered for documented chronic sinus infection refractory to medical therapy with anatomic obstruction 2