What is the treatment for post nasal drip?

Treatment for Postnasal Drip

For non-allergic postnasal drip, start with a first-generation antihistamine plus decongestant combination (such as dexbrompheniramine with sustained-release pseudoephedrine), while for allergic causes, intranasal corticosteroids are the most effective first-line monotherapy. 1, 2

Treatment Algorithm Based on Underlying Cause

Non-Allergic Rhinitis-Related Postnasal Drip

• First-generation antihistamine/decongestant combinations are superior to newer non-sedating antihistamines due to their anticholinergic properties that reduce secretions. 1, 2

• Effective combinations include:

  • Dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate 1, 2
  • Azatadine maleate plus sustained-release pseudoephedrine sulfate 1, 2

• Treat for a minimum of 3 weeks for chronic cases. 1

• Most patients improve within days to 2 weeks of starting therapy. 1, 2

• To minimize sedation, start with once-daily dosing at bedtime before advancing to twice-daily therapy. 1, 2

Allergic Rhinitis-Related Postnasal Drip

• Intranasal corticosteroids (such as fluticasone propionate or budesonide) are the most effective monotherapy and should be tried for a minimum of 1 month. 1, 3

• Alternative first-line options include oral antihistamines and/or cromolyn nasal spray. 1, 2

• Leukotriene modifiers (montelukast) can decrease symptoms of allergic rhinitis and may be added as adjunctive therapy. 1, 2

• For fluticasone propionate nasal spray, adults can use 200 mcg once daily (two 50-mcg sprays per nostril) or 100 mcg twice daily. 3

• Symptom improvement may begin as early as 12 hours, but maximum effect typically requires several days. 3

Second-Line and Alternative Therapies

• Ipratropium bromide nasal spray is highly effective for reducing rhinorrhea and postnasal drip, particularly in patients who don't respond to or have contraindications to antihistamine/decongestant combinations. 4, 1, 2

• Cromolyn nasal spray shows benefit in managing both seasonal and perennial allergic rhinitis. 4

• Oral decongestants (pseudoephedrine) relieve nasal congestion but not other symptoms. 4

Critical Considerations and Common Pitfalls

Medication Selection Errors

• Newer-generation non-sedating antihistamines are significantly less effective for non-allergic postnasal drip compared to first-generation agents. 1, 2

• Second-generation antihistamines may be more appropriate for allergic rhinitis than non-allergic causes. 2

• Never use topical nasal decongestants (such as oxymetazoline) for more than 3-5 consecutive days due to risk of rhinitis medicamentosa (rebound congestion). 1, 5

"Silent" Postnasal Drip

• Approximately 20% of patients with postnasal drip-induced symptoms have no obvious sensation of drainage but still respond to treatment. 1, 2

• Failure to consider this "silent" presentation can lead to missed diagnoses. 1, 2

• Look for cobblestone appearance of the oropharyngeal mucosa on examination. 1

Side Effects to Monitor

• First-generation antihistamines commonly cause dry mouth and transient dizziness. 1, 2

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

• Intranasal corticosteroids may cause epistaxis, headache, and pharyngitis. 4

• Ipratropium can cause significant nasal dryness and irritation. 4

• Oral decongestants can cause insomnia, irritability, palpitations, and hypertension. 1

Treatment for Specific Underlying Conditions

Acute Bacterial Sinusitis

• Treatment includes antibiotics, intranasal corticosteroids, and decongestants. 1

• Intranasal corticosteroids administered with antibiotics facilitate more rapid symptom improvement. 6

Chronic Sinusitis

• Requires a minimum of 3 weeks of antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae. 1

• Add 3 weeks of oral antihistamine/decongestant combination. 1

• Use nasal decongestant for maximum of 5 days. 1

• Follow with 3 months of intranasal corticosteroids for maintenance. 1

• Long-term low-dose macrolide therapy may be effective for intractable cases. 7

Rhinitis from Physical or Chemical Irritants

• Primary management involves avoidance of exposure, improved ventilation, filters, and personal protective devices. 1

• Medical therapy can be added as needed for symptom control. 1

Special Populations and Dosing

Pediatric Patients (4 years and older)

• Start with fluticasone propionate 100 mcg (one spray per nostril once daily). 3

• Reserve 200 mcg daily dosing for inadequate responders. 3

• Once control is achieved, decrease to 100 mcg daily. 3

• Maximum dose should not exceed 200 mcg/day (two sprays per nostril). 3

As-Needed Use (Seasonal Allergic Rhinitis in patients ≥12 years)

• Some patients may use fluticasone propionate as-needed (not exceeding 200 mcg daily) for symptom control. 3

• However, scheduled regular use typically achieves greater symptom control. 3

• As-needed use has not been studied in children under 12 years or in perennial rhinitis. 3

Diagnostic Considerations

• Symptoms and clinical findings are not reliable discriminators for postnasal drip diagnosis. 1, 2

• Postnasal drip can be confused with gastroesophageal reflux disease (GERD). 1, 2

• In patients with chronic cough and excess sputum production, sinus radiographs have 81% positive predictive value and 95% negative predictive value for chronic sinusitis causing postnasal drip. 2

• Recent evidence suggests chronic idiopathic postnasal drip may be a distinct entity, with 71.6% of patients responding to first-generation antihistamine-decongestant therapy. 8