What are the treatment options for post nasal drip?

Treatment for Post Nasal Drip

For post nasal drip (now termed Upper Airway Cough Syndrome), start with a first-generation antihistamine plus decongestant combination (such as dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate) 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, 3

First-Line Treatment Algorithm

Initial Therapy

• Begin with first-generation antihistamine/decongestant combinations taken for at least 3 weeks, as most patients improve within days to 2 weeks but chronic cases require longer treatment 1, 2, 3
• To minimize sedation, start with once-daily dosing at bedtime for the first few days, then increase to twice-daily therapy after tolerance develops 1, 3
• Effective specific combinations include:
  • Dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate 2, 3
  • Azatadine maleate plus sustained-release pseudoephedrine sulfate 2, 3

Why First-Generation Over Newer Antihistamines

• Newer-generation antihistamines are less effective for non-allergic causes of postnasal drip because they lack the anticholinergic properties that help dry secretions 1, 3
• First-generation antihistamines work through both antihistaminic and anticholinergic mechanisms 3

Add-On Therapy for Allergic Rhinitis

If allergic rhinitis is the underlying cause:

• Add intranasal corticosteroids (such as fluticasone 100-200 mcg daily) for a 1-month trial alongside the antihistamine/decongestant combination 4, 1, 3
• Intranasal corticosteroids are the most effective monotherapy for allergic rhinitis-related postnasal drip 1
• Alternative options include cromolyn or oral leukotriene inhibitors 3

Proper Intranasal Steroid Technique

• Shake the bottle well before use 5
• Look down by bending your neck toward the floor 4
• Use your right hand for the left nostril and left hand for the right nostril 4
• Aim toward the outer wall, NOT toward the nasal septum to prevent irritation and bleeding 4
• Do not sniff hard after spraying 4

Expected Timeline for Intranasal Steroids

• You may start to feel relief the first day, but it takes several days to build up to full effectiveness 5
• No rebound effect occurs with intranasal corticosteroids, unlike nasal decongestant sprays 5
• Can be used for up to 6 months in patients age 12 or older, or up to 2 months per year in children age 4-11 5

Second-Line Options

For Patients Who Cannot Tolerate First-Line Therapy

• Ipratropium bromide nasal spray is an effective alternative for patients who don't respond to antihistamine/decongestant combinations or have contraindications (such as uncontrolled hypertension, glaucoma, or urinary retention) 1, 2, 3
• This provides anticholinergic drying effects without systemic cardiovascular side effects 3

For Chronic Sinusitis with Postnasal Drip

• Minimum of 3 weeks of antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae 1, 2
• Combined with 3 weeks of oral antihistamine/decongestant 1, 2
• Plus 5 days of nasal decongestant 1, 2
• Followed by 3 months of intranasal corticosteroids 1, 2

Adjunctive Therapy: Nasal Saline Irrigation

Evidence for Saline Irrigation

• Nasal saline irrigation improves symptoms through mechanical removal of mucus, enhanced ciliary activity, and disruption of inflammatory mediators 4
• More effective than saline spray because irrigation better expels secretions 4
• Can be used as sole therapy or as adjunct to intranasal steroids 4

How to Use Saline Irrigation

• Use isotonic or hypertonic saline solution (evidence insufficient to support superiority of either) 4
• Delivery methods include Neti pot, squeeze bottle, bulb/syringe, or pulsatile irrigation 4
• The optimal frequency is uncertain, but longer treatment duration (mean 7.5 months) shows better results than shorter courses 4
• Common side effect is fluid dripping from the nose 4

Critical Pitfalls and Caveats

Decongestant Safety

• Monitor blood pressure after initiating decongestants, as they can worsen hypertension and cause tachycardia 3
• Common side effects include insomnia, urinary retention, jitteriness, and increased intraocular pressure in glaucoma patients 1, 3
• NEVER use topical nasal decongestants (oxymetazoline, xylometazoline) for more than 3-5 consecutive days due to risk of rhinitis medicamentosa (rebound congestion) 4, 1

Antihistamine Side Effects

• Common: dry mouth and transient dizziness 1, 3
• Starting with bedtime dosing minimizes daytime sedation 1, 3

Recognizing "Silent" Postnasal Drip

• Approximately 20% of patients have no obvious postnasal drip symptoms yet still respond to treatment 1, 3
• Failure to consider this can lead to missed diagnoses 1
• Look for cobblestoning of the posterior pharyngeal wall on examination 3

When to Suspect Other Causes

• If symptoms don't improve after 1-2 weeks of adequate upper airway treatment, consider gastroesophageal reflux disease (GERD) or asthma 3
• Postnasal drip can be confused with GERD symptoms 1, 3
• If severe sinus pain or thick nasal discharge develops, stop treatment and evaluate for bacterial sinusitis 5

Special Populations

Pregnancy

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

Children

• For ages 4-11: use 1 spray of intranasal corticosteroid in each nostril once daily 5
• Growth rate may be slower while using intranasal steroids; use for shortest time necessary to achieve symptom relief 5
• Talk to doctor if child needs to use spray for longer than 2 months per year 5
• Do not use in children under 4 years of age 5

Patients with Contraindications to Decongestants

• Avoid oral decongestants in patients with uncontrolled hypertension, severe coronary artery disease, glaucoma, urinary retention, or hyperthyroidism 3
• Use ipratropium bromide nasal spray or intranasal corticosteroids alone instead 3