What is the treatment for postnasal drip?

Treatment of Postnasal Drip

For postnasal drip, start with a first-generation antihistamine plus decongestant combination (such as dexbrompheniramine with sustained-release pseudoephedrine or azatadine with sustained-release pseudoephedrine) taken for a minimum of 3 weeks, as this is the most effective first-line treatment regardless of whether the cause is allergic or non-allergic rhinitis. 1, 2

First-Line Treatment Algorithm

Non-Allergic Rhinitis (Most Common)

• Begin with first-generation antihistamine/decongestant combinations as the primary treatment 3, 1, 2
• Specific effective combinations include:
  • Dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate 1, 2
  • Azatadine maleate plus sustained-release pseudoephedrine sulfate 1, 2
• Minimum treatment duration is 3 weeks for chronic cases 1
• Most patients improve within days to 2 weeks of starting therapy 1, 2

Allergic Rhinitis

• Intranasal corticosteroids are the most effective monotherapy for allergic rhinitis-related postnasal drip 1
• Require a 1-month trial (fluticasone 100-200 mcg daily or equivalent) 1, 2
• Alternative options include oral antihistamines, cromolyn, or leukotriene blockers 3, 1, 2
• Can combine intranasal corticosteroids with first-generation antihistamine/decongestant for enhanced effect 2

Dosing Strategy to Minimize Side Effects

• Start with once-daily dosing at bedtime for the first few days to minimize sedation from first-generation antihistamines 1, 2
• Increase to twice-daily therapy after tolerance develops 1, 2
• Common side effects include dry mouth and transient dizziness 1, 2
• Monitor for serious side effects: insomnia, urinary retention, jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 1, 2

Second-Line and Alternative Treatments

If First-Line Fails or Contraindicated

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

For Chronic Sinusitis with Postnasal Drip

• Minimum 3 weeks of antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae 1
• Combine with 3 weeks of oral antihistamine/decongestant 1
• Add 5 days of nasal decongestant 1
• Follow with 3 months of intranasal corticosteroids 1

For Rhinitis Due to Physical/Chemical Irritants

• Avoidance of exposure is primary treatment 1
• Improved ventilation, filters, and personal protective devices 1

Critical Pitfalls and Caveats

Common Mistakes to Avoid

• Never use newer-generation (non-sedating) antihistamines for non-allergic postnasal drip - they are significantly less effective due to lack of anticholinergic properties 1, 2
• Never use topical decongestants for more than 3-5 consecutive days - this causes rhinitis medicamentosa (rebound congestion) 1
• Approximately 20% of patients have "silent" postnasal drip with no obvious symptoms of drainage but still respond to treatment 1, 2
• Postnasal drip can be confused with gastroesophageal reflux disease (GERD) - if cough persists despite adequate upper airway treatment, consider an 8-12 week trial of proton pump inhibitors 1, 2

Diagnostic Considerations

• Symptoms and physical findings are not reliable discriminators for establishing postnasal drip as the cause 2
• Response to treatment is the definitive diagnostic approach 3, 2
• Look for cobblestone appearance of oropharyngeal mucosa, throat clearing, and sensation of drainage 1, 2

Special Populations and Considerations

Pregnancy

• Use caution with decongestants during the first trimester due to potential fetal heart rate changes 1

Chronic Nasal Polyps

• Short courses of oral corticosteroids (prednisolone 25-60 mg daily for 2 weeks) followed by intranasal corticosteroids show significant improvement in postnasal drip symptoms 3
• Prednisolone-treated groups showed significantly greater improvements in nasal symptoms including postnasal drip at 2,7, and 12 weeks compared to placebo 3

Refractory Cases

• Consider posterior nasal nerve ablation for medically refractory postnasal drip after failure of anticholinergic nasal sprays, reflux treatments, and nasal steroids 4
• Endoscopic sinus surgery should only be considered for documented chronic sinus infection refractory to medical therapy with anatomic obstruction 1