What is the treatment for post nasal drip?

Treatment for Postnasal Drip

Start with a first-generation antihistamine plus decongestant combination (such as dexbrompheniramine plus sustained-release pseudoephedrine or azatadine plus sustained-release pseudoephedrine) for a minimum of 3 weeks, regardless of whether the cause is allergic or non-allergic rhinitis. 1, 2

First-Line Treatment Strategy

• Begin with once-daily dosing at bedtime for the first few days to minimize sedation, then increase to twice-daily therapy after tolerance develops 1, 3
• Most patients will experience improvement within days to 2 weeks of starting therapy 1, 3
• The anticholinergic properties of first-generation antihistamines are critical for efficacy—newer non-sedating antihistamines are significantly less effective for postnasal drip, particularly when the cause is non-allergic 1, 3

When to Add Intranasal Corticosteroids

• If symptoms persist after 1-2 weeks of antihistamine-decongestant therapy, add intranasal corticosteroids (fluticasone 100-200 mcg daily) for a 1-month trial 1, 3
• For allergic rhinitis specifically, nasal corticosteroids can be started as first-line therapy alongside antihistamines 4, 1
• Intranasal corticosteroids are effective for both allergic and non-allergic rhinitis-related postnasal drip 3

Alternative and Second-Line Options

• Ipratropium bromide nasal spray is an effective alternative for patients who cannot tolerate or have contraindications to decongestants (such as uncontrolled hypertension, cardiac arrhythmias, or glaucoma) 1, 2
• The combination of ipratropium bromide plus intranasal corticosteroid is more effective than either drug alone for treating rhinorrhea without increased adverse events 2
• Leukotriene blockers can decrease symptoms of allergic rhinitis and may be added as adjunctive therapy 4, 1

Treatment Based on Underlying Cause

For Allergic Rhinitis:

• Nasal corticosteroids, antihistamines, and/or cromolyn are appropriate first-line choices 4, 3
• Avoidance of allergens when possible, though complete avoidance is usually not feasible 4

For Chronic Sinusitis with Postnasal Drip:

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

For Rhinitis Due to Irritants:

• Avoidance of exposure, improved ventilation, filters, and personal protective devices 1

Adjunctive Therapy

• Nasal saline irrigation improves symptoms through mechanical removal of mucus and enhanced ciliary activity—irrigation is more effective than saline spray because it better expels secretions 3
• Longer treatment duration (mean 7.5 months) shows better results than shorter courses 3

Critical Pitfalls and Contraindications

• NEVER use topical nasal decongestants (oxymetazoline, xylometazoline) for more than 3-5 consecutive days due to risk of rhinitis medicamentosa (rebound congestion) 1, 3
• Monitor blood pressure after initiating oral decongestants, as they can worsen hypertension and cause tachycardia 3
• Use oral and topical decongestants with extreme caution in older adults, young children, and patients with cardiac arrhythmia, angina, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism 2
• Common side effects of first-generation antihistamines include dry mouth and transient dizziness 1, 3
• More serious side effects include insomnia, urinary retention, jitteriness, tachycardia, worsening hypertension, and increased intraocular pressure in glaucoma patients 1, 3

Special Considerations

• Approximately 20% of patients have "silent" postnasal drip with no obvious symptoms yet still respond to treatment 1, 3
• If symptoms persist despite adequate upper airway treatment for 2 weeks, proceed with sequential evaluation for other causes including asthma and gastroesophageal reflux disease 3
• Postnasal drip can sometimes be confused with GERD—if cough persists despite adequate upper airway treatment, consider empiric proton pump inhibitor therapy (omeprazole 20-40 mg twice daily before meals) for at least 8 weeks 3
• In pregnancy, use caution with decongestants during the first trimester due to potential fetal heart rate changes 2