What treatment options are available for post nasal drip?

Treatment for Post Nasal Drip

Start with a first-generation antihistamine/decongestant combination (such as dexbrompheniramine plus sustained-release pseudoephedrine or azatadine plus sustained-release pseudoephedrine) as first-line therapy, as this is the most effective treatment for postnasal drip cough according to the American College of Chest Physicians. 1

First-Line Treatment Approach

• First-generation antihistamine/decongestant combinations are superior to newer non-sedating antihistamines due to their anticholinergic drying properties, which are essential for controlling postnasal drip symptoms 1
• Begin with once-daily dosing at bedtime for a few days to minimize sedation, then increase to twice-daily therapy as tolerated 1
• Most patients will see improvement within days to 2 weeks of starting therapy 1

Add Nasal Saline Irrigation

• The American Academy of Otolaryngology-Head and Neck Surgery recommends nasal saline irrigation as a beneficial adjunct treatment because it improves mucus clearance, enhances ciliary activity, and removes inflammatory mediators 2
• High-volume saline rinsing is more effective than low-volume rinsing or sprays for reducing purulent rhinorrhea and postnasal drip 2
• Use clean water and proper technique to avoid infection risk; do not share nasal delivery devices 2

If Allergic Rhinitis is Present

• Add intranasal corticosteroids (fluticasone 100-200 mcg daily) for a 1-month trial alongside the antihistamine/decongestant combination 1, 3
• Fluticasone decreases vascular permeability and inhibits inflammatory cell infiltration, particularly eosinophils 4
• Some patients may see symptom improvement as early as 12 hours, but maximum effect may take several days 3
• Alternative options include oral leukotriene inhibitors, which decrease allergic rhinitis symptoms 1

If Standard Treatment Fails or Contraindications Exist

• Ipratropium bromide nasal spray is the alternative for patients who don't respond to antihistamine/decongestant combinations or have contraindications (such as uncontrolled hypertension, glaucoma, or urinary retention) 1
• This provides anticholinergic drying effects without systemic cardiovascular side effects 1

Important Monitoring and Side Effects

• Common side effects of first-generation antihistamines include dry mouth and transient dizziness 1
• Monitor for serious side effects: insomnia, urinary retention, jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 1
• Check blood pressure after initiating decongestant therapy, as it can worsen hypertension 1
• Avoid topical decongestants beyond 3-5 days to prevent rebound congestion (rhinitis medicamentosa) 4

When to Escalate Care

• If symptoms persist after 2 weeks of adequate upper airway treatment, evaluate sequentially for asthma and gastroesophageal reflux disease (GERD) 1
• Consider GERD treatment with proton pump inhibitors (omeprazole 20-40 mg twice daily before meals) for at least 8 weeks if clinical profile suggests reflux, as postnasal drip can be confused with GERD 1
• If symptoms persist after 3-4 weeks of appropriate medical therapy, obtain sinus imaging to evaluate for chronic sinusitis or anatomical abnormalities 4

Critical Pitfalls to Avoid

• Newer-generation antihistamines (like cetirizine or loratadine) are ineffective for non-allergic postnasal drip and should not be used as monotherapy 1
• Approximately 20% of patients have "silent" postnasal drip with no obvious symptoms yet still respond to treatment—don't dismiss the diagnosis based on lack of visible drainage 1
• Antibiotics are not indicated unless there is clear evidence of bacterial sinusitis 4
• Treatment should be directed at the specific underlying cause when identified rather than using purely empiric therapy 1