What are the treatment options for post nasal drip?

Treatment of Postnasal Drip

First-Line Treatment: Start with First-Generation Antihistamine Plus Decongestant

For postnasal drip, regardless of whether the cause is allergic or non-allergic rhinitis, begin with a first-generation antihistamine plus decongestant combination for a minimum of 3 weeks, as this is the most effective first-line treatment. 1, 2

Specific Effective Combinations

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

Dosing Strategy to Minimize Side Effects

• Start with once-daily dosing at bedtime for the first few days to minimize sedation 1, 3
• After tolerance develops (typically a few days), increase to twice-daily therapy 1, 3
• Most patients will see improvement within days to 2 weeks of initiating therapy 1, 2, 3
• Continue treatment for a minimum of 3 weeks for chronic cases 1, 2

Why First-Generation Over Newer Antihistamines

• First-generation antihistamines are superior to newer non-sedating antihistamines due to their anticholinergic properties, which are essential for treating non-allergic causes of postnasal drip 3
• Newer-generation antihistamines are less effective for non-allergic causes of postnasal drip cough 2, 3
• Studies show no consistent benefit of sedating over nonsedating antihistamines for allergic rhinitis, but the anticholinergic effects make first-generation agents more effective for postnasal drip specifically 4

Second-Line Treatment Options

For Allergic Rhinitis-Related Postnasal Drip

• Intranasal corticosteroids (such as fluticasone 100-200 mcg daily) are highly effective and should be tried for a 1-month trial 2, 3, 5
• Can be used as monotherapy or combined with the antihistamine/decongestant regimen 2
• Alternative options include cromolyn or oral leukotriene inhibitors 2, 3

For Patients Who Don't Respond or Have Contraindications

• Ipratropium bromide nasal spray is an effective alternative that specifically reduces rhinorrhea and postnasal drip 4, 1, 2, 3
• Particularly useful for patients who cannot tolerate antihistamine/decongestant combinations 1, 2

Treatment for Chronic Sinusitis with Postnasal Drip

When chronic sinusitis is the underlying cause:

• Minimum 3 weeks of antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae 1, 2
• 3 weeks of oral antihistamine/decongestant 1, 2
• 5 days of nasal decongestant (never exceed 5 days to avoid rhinitis medicamentosa) 1, 2
• Followed by 3 months of intranasal corticosteroids 1, 2

Side Effects to Monitor

Common Side Effects

• Dry mouth and transient dizziness from first-generation antihistamines 2, 3
• Nasal dryness and irritation from ipratropium 4
• Epistaxis, headache, and pharyngitis from nasal corticosteroids 4

Serious Side Effects Requiring Monitoring

• Insomnia, urinary retention, jitteriness 2, 3
• Tachycardia and worsening hypertension 2, 3
• Increased intraocular pressure in glaucoma patients 2, 3

Critical Pitfalls to Avoid

Topical Decongestant Overuse

• Never use topical decongestants for more than 3-5 consecutive days due to risk of rhinitis medicamentosa (rebound congestion) 2
• Long-term use can cause worsening symptoms that are difficult to reverse 2

"Silent" Postnasal Drip

• Approximately 20% of patients have no obvious symptoms of postnasal drip yet still respond to treatment 2, 3
• Consider empiric treatment even when physical examination findings are minimal 2, 3
• The diagnosis is often confirmed by successful response to treatment rather than objective findings 3

Misdiagnosis Considerations

• Postnasal drip can be confused with gastroesophageal reflux disease (GERD) 2, 3
• If cough persists despite adequate upper airway treatment, consider GERD and trial proton pump inhibitors (omeprazole 20-40 mg twice daily before meals for at least 8 weeks) 3

Special Populations

Pregnancy

• Use caution with decongestants during the first trimester due to potential fetal heart rate changes 1, 2

Chronic Nasal Polyps

• Short courses of oral corticosteroids (such as prednisolone) followed by intranasal corticosteroids show significant improvement at 2,7, and 12 weeks 1

Treatment Duration Expectations

• Acute cases: Improvement typically within days to 2 weeks 1, 2, 3
• Chronic rhinitis: Minimum 3 weeks of treatment required 1, 2
• Allergic rhinitis with intranasal corticosteroids: 1-month trial recommended 2, 3
• Chronic sinusitis: 3 weeks of combination therapy followed by 3 months of intranasal corticosteroids 1, 2