What is the treatment for severe post nasal drip?

Treatment of Severe Postnasal Drip

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 for severe postnasal drip regardless of whether the cause is allergic or non-allergic rhinitis. 1

First-Line Treatment Strategy

• Begin with once-daily dosing at bedtime for the first few days to minimize sedation from first-generation antihistamines, then increase to twice-daily therapy after tolerance develops 1
• Most patients will see improvement within days to 2 weeks of initiating therapy, though the minimum treatment duration for chronic cases is 3 weeks 1, 2
• Effective combinations include dexbrompheniramine maleate plus sustained-release pseudoephedrine sulfate, or azatadine maleate plus sustained-release pseudoephedrine sulfate 1, 2

When to Add Intranasal Corticosteroids

• If symptoms persist after 1-2 weeks of antihistamine/decongestant therapy, add intranasal corticosteroids such as fluticasone propionate 100-200 mcg daily (2 sprays per nostril once daily) for a 1-month trial 2, 3
• Intranasal corticosteroids are particularly effective for allergic rhinitis-related postnasal drip and have been shown to significantly decrease total nasal symptom scores including postnasal drip, nasal obstruction, and rhinorrhea 4
• The combination of ipratropium bromide nasal spray and intranasal corticosteroid is more effective than either drug alone for treating rhinorrhea without increased adverse events 5

Second-Line Options

• For patients who don't respond to antihistamine/decongestant combinations or have contraindications (such as hypertension, cardiac disease, glaucoma, or hyperthyroidism), use ipratropium bromide nasal spray as an alternative 1, 2
• Ipratropium bromide effectively reduces rhinorrhea through anticholinergic drying effects without systemic cardiovascular side effects, though it has no effect on other nasal symptoms 5

Adjunctive Therapy

• Add nasal saline irrigation to any regimen, as it improves symptoms through mechanical removal of mucus, enhanced ciliary activity, and disruption of inflammatory mediators 3
• Nasal saline irrigation is more effective than saline spray because irrigation better expels secretions 3
• Longer treatment duration (mean 7.5 months) shows better results than shorter courses 3

Treatment for Underlying Chronic Sinusitis

• If chronic sinusitis is present, prescribe a minimum of 3 weeks of antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae, combined with 3 weeks of oral antihistamine/decongestant and 5 days of nasal decongestant, followed by 3 months of intranasal corticosteroids 1, 2

Critical Pitfalls to Avoid

• Never use topical nasal decongestants (oxymetazoline, xylometazoline) for more than 3-5 consecutive days due to the risk of rhinitis medicamentosa (rebound congestion) 2, 3
• Newer-generation antihistamines are less effective for non-allergic causes of postnasal drip and should not be substituted for first-generation antihistamines 2, 3
• Use oral and topical decongestants with caution in older adults, young children, and patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism 5
• Monitor for side effects including insomnia, urinary retention, jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 2, 3

Special Considerations

• Approximately 20% of patients have "silent" postnasal drip with no obvious symptoms yet still respond to treatment 2
• In pregnancy, use caution with decongestants during the first trimester due to potential fetal heart rate changes 1
• For chronic nasal polyps, consider short courses of oral corticosteroids (5-7 days) followed by intranasal corticosteroids, which show significant improvement in postnasal drip symptoms 5, 1
• Recent evidence suggests that 71.6% of patients with chronic idiopathic postnasal drip respond positively to first-generation antihistamine-decongestant medication, though 25.9% may experience symptom recurrence 6