What are the treatment options for post nasal drip?

Treatment of Postnasal Drip

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

Begin treatment with a first-generation antihistamine/decongestant combination for a minimum of 3 weeks, regardless of whether the cause is allergic or non-allergic rhinitis. 1, 2 This is the most effective first-line therapy and superior to newer-generation antihistamines due to the anticholinergic drying properties of older antihistamines. 3, 4

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 allow tolerance to develop and minimize sedation 1, 2
• After 3-5 days, increase to twice-daily dosing 1, 2
• Most patients improve within days to 2 weeks of starting therapy 1, 2

Important Contraindications and Monitoring:

• Use decongestants with extreme caution in patients with hypertension, cardiac arrhythmia, angina, cerebrovascular disease, bladder neck obstruction, glaucoma, or hyperthyroidism 1
• Monitor blood pressure after initiating decongestant therapy 4
• Common side effects include dry mouth, transient dizziness, insomnia, urinary retention, jitteriness, tachycardia, and worsening hypertension 2

Second-Line Treatment: Add Intranasal Corticosteroids

If no improvement after 1-2 weeks with antihistamine/decongestant combination, add intranasal corticosteroids such as fluticasone 100-200 mcg daily for a 1-month trial. 2, 4, 5

Intranasal Corticosteroid Specifics:

• Fluticasone propionate can be dosed as 200 mcg once daily (two 50-mcg sprays per nostril) or 100 mcg twice daily (one 50-mcg spray per nostril twice daily) 5
• Maximum effect may take several days, though some improvement may occur within 12 hours 5
• Intranasal corticosteroids are the most effective monotherapy for allergic rhinitis and also effective for non-allergic rhinitis 4
• Available options include fluticasone propionate, mometasone furoate, or triamcinolone 4

For Allergic Rhinitis Specifically:

• Nasal corticosteroids, antihistamines, and/or cromolyn are appropriate initial choices 3, 2
• Oral leukotriene inhibitors can decrease symptoms of allergic rhinitis 3, 2
• Nonsedating antihistamines are more effective for allergic rhinitis than non-allergic rhinitis 3

Alternative and Adjunctive Therapies

Ipratropium Bromide Nasal Spray:

For patients who don't respond to antihistamine/decongestant combinations or have contraindications (especially cardiovascular), use ipratropium bromide nasal spray 42 mcg per spray, 2 sprays per nostril 4 times daily. 1, 2, 4 This provides anticholinergic drying effects without systemic cardiovascular side effects, though it only reduces rhinorrhea and has no effect on other nasal symptoms. 1

Combination Therapy for Severe Cases:

• The combination of ipratropium bromide nasal spray plus intranasal corticosteroid is more effective than either drug alone without increased adverse events 1

Nasal Saline Irrigation:

• Nasal saline irrigation improves symptoms through mechanical removal of mucus, enhanced ciliary activity, and disruption of inflammatory mediators 4
• Irrigation is more effective than saline spray because it better expels secretions 4
• Longer treatment duration (mean 7.5 months) shows better results than shorter courses 4

Treatment for Chronic Sinusitis with Postnasal Drip

For chronic sinusitis causing postnasal drip, use 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

Treatment for Nasal Polyps with Postnasal Drip

Short courses of oral corticosteroids (5-7 days) followed by intranasal corticosteroids show significant improvement in postnasal drip symptoms. 1 Prednisolone-treated groups show significantly greater improvements in nasal symptoms at 2,7, and 12 weeks compared to placebo. 1

Critical Pitfalls to Avoid

Never Use Topical Decongestants Long-Term:

NEVER use topical nasal decongestants (oxymetazoline, xylometazoline) for more than 3-5 consecutive days due to the risk of rhinitis medicamentosa (rebound congestion). 2, 4 This paradoxical worsening of nasal congestion occurs with persistent use and can only be terminated by cessation of the topical vasoconstrictor. 3

Recognize "Silent" Postnasal Drip:

• Approximately 20% of patients have no obvious postnasal drip symptoms yet still respond to treatment 2, 4
• Failure to consider "silent" postnasal drip as a causative factor for chronic cough leads to missed diagnoses 2

Newer-Generation Antihistamines Are Less Effective:

Newer-generation antihistamines are less effective for non-allergic causes of postnasal drip because they lack the anticholinergic properties that provide the drying effect needed for symptom control. 2, 4

Consider Multiple Causes:

• Upper airway cough syndrome, asthma, and GERD together account for approximately 90% of chronic cough cases 4
• If symptoms persist despite adequate upper airway treatment for 2 weeks, proceed with sequential evaluation for asthma/non-asthmatic eosinophilic bronchitis and GERD 4
• Maintain all partially effective treatments rather than discontinuing them prematurely, as multiple causes may coexist 4

Special Populations

Pregnancy:

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

Pediatric Patients:

• Intranasal corticosteroids may cause reduction in growth velocity 5
• Children 4 years and older should start with 100 mcg (1 spray per nostril once daily), with maximum dose not exceeding 200 mcg/day 5

Elderly and High-Risk Patients:

• 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 1

Monitoring and Follow-Up

• Patients using intranasal corticosteroids for several months should be examined periodically for evidence of Candida infection or other adverse effects on nasal mucosa 5
• Monitor for rare complications including nasal septum perforation, cataracts, glaucoma, and increased intraocular pressure 5
• If systemic corticosteroid effects occur (hypercorticism, adrenal suppression), discontinue intranasal corticosteroids slowly using accepted procedures for discontinuing oral corticosteroid therapy 5