This guide is based on practice guidelines from the American College of Chest Physicians. The 2006 guidelines remain up-to-date as of 2025 as they are effective. 

Postnasal drip occurs when excess mucus drips down the back of the throat, often due to allergies, infections, or irritants. This can cause coughing, a feeling of throat obstruction, and excessive throat clearing. Persistent symptoms after over-the-counter treatment warrants further evaluation.

First-line recommendations:

• Antihistamine-decongestant combination: The American College of Chest Physicians (ACCP) recommends a diagnostic/therapeutic trial of a first-generation antihistamine-decongestant combination (e.g., chlorpheniramine and pseudoephedrine) as the initial approach. Improvement in cough within 1 to 2 weeks of initiating therapy suggests UACS as the cause, and the therapy should be continued. Recommended product. Rite Aid Sinus & Allergy Relief Tablets (FDA M012).

Second-line recommendations: 

• Intranasal steroids: Fluticasone propionate at 50 mcg per spray, 2 sprays in each nostril once daily can be tried if the response to the first-line therapy is partial or if nasal symptoms persist. Flonase Allergy Relief Nasal Spray (FDA NDA 205434)

• Intranasal antihistamines (e.g., azelastine): may be effective at further reducing nasal inflammation. As needed or 2 sprays in each nostril per day. Dose: 0.1% (137 mcg/spray). Astepro Steroid-Free Nasal Spray (FDA NDA 213872).

Further evaluation and treatment: 

• Antibiotic therapy: If sinusitis is suspected based on imaging (e.g., air-fluid levels in the sinuses), antibiotic therapy may be indicated. 

• Asthma testing: lung function tests may be formed if asthma is suspected

• Allergy testing: Performed for recurrent or persistent symptoms to identify specific triggers.

Citation

Pratter, M. R., Brightling, C. E., Boulet, L. P., & Irwin, R. S. (2006). An empiric integrative approach to the management of cough: ACCP evidence-based clinical practice guidelines. Chest, 129(1), 222S-231S.