What are the treatment options for 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 older-generation antihistamines being superior to newer non-sedating antihistamines due to their anticholinergic properties. 1

First-Line Treatment Algorithm

For Non-Allergic Rhinitis (Most Common)

• Start with first-generation antihistamine plus decongestant combination such as dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate, or azatadine maleate plus sustained-release pseudoephedrine sulfate 1, 2
• To minimize sedation, begin with once-daily dosing at bedtime for a few days before increasing to twice-daily therapy 1
• Continue treatment for a minimum of 3 weeks for chronic cases 2
• Most patients will see improvement within days to 2 weeks 1

For Allergic Rhinitis

• Intranasal corticosteroids are the most effective monotherapy for allergic causes 2
• Use fluticasone propionate nasal spray: 2 sprays in each nostril once daily for week 1, then 1-2 sprays once daily for weeks 2 through 6 months 3
• Relief may start the first day, but full effectiveness takes several days 3
• Alternative options include oral antihistamines, cromolyn, or leukotriene inhibitors 4, 1
• A 1-month trial is recommended before assessing efficacy 1, 2

Adjunctive Therapy: Nasal Saline Irrigation

• Add high-volume nasal saline irrigation to any treatment regimen as it improves mucus clearance, enhances ciliary activity, and removes inflammatory mediators 5
• Irrigation is more effective than saline spray for expelling secretions 5
• Use clean water and proper technique; do not share nasal delivery devices to prevent infection 5
• Common side effect is fluid dripping from the nose, which is generally well-tolerated 5

Alternative Treatment Options

For Patients Who Don't Respond or Have Contraindications

• Ipratropium bromide nasal spray is an effective alternative for patients who don't respond to antihistamine/decongestant combinations 1, 2

For Chronic Sinusitis

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

Critical Pitfalls to Avoid

Medication Selection Errors

• Never use newer-generation antihistamines alone for non-allergic post nasal drip - they are significantly less effective than first-generation antihistamines 1, 2
• Avoid topical decongestants for more than 3-5 days as they cause rhinitis medicamentosa (rebound congestion) 2
• Intranasal corticosteroids like fluticasone do NOT cause rebound effect and can be used safely for up to 6 months 3

Monitoring for Side Effects

• Common side effects of first-generation antihistamines include dry mouth and transient dizziness 1
• More serious side effects to watch for: insomnia, urinary retention, jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 1
• Decongestants can cause insomnia, irritability, palpitations, and hypertension 2

Diagnostic Considerations

• Approximately 20% of patients have "silent" post nasal drip with no obvious symptoms yet still respond to treatment 2
• If symptoms don't improve after 1 week of treatment, stop and evaluate for possible sinus infection 3
• If severe sinus pain or thick nasal discharge develops, consider bacterial sinusitis requiring antibiotics 3

Special Populations

Children (4-11 years)

• Use 1 spray of fluticasone in each nostril once daily 3
• Growth rate may be slower with prolonged use; use for shortest time necessary 3
• If needed for longer than 2 months per year, consult pediatrician 3

Adults and Children ≥12 years

• Can use fluticasone for up to 6 months before checking with doctor 3
• Week 1: 2 sprays each nostril once daily; Weeks 2-6 months: 1-2 sprays once daily as needed 3

When to Refer or Escalate

• Consider endoscopic sinus surgery only for documented chronic sinus infection refractory to medical therapy with anatomic obstruction 2
• Refer to otolaryngologist if symptoms are persistent, unexplainable, or associated with warning signs of malignancy 6
• Stop treatment and see doctor immediately for: sudden swelling of face or tongue, rash, wheezing, feeling faint, severe or frequent nosebleeds, or constant whistling sound from nose 3