What are the recommended medications and dosages for cold management?

Cold Management: Recommended Medications and Dosages

For adults with the common cold, combination antihistamine-decongestant-analgesic products provide the most significant symptom relief, with approximately 1 in 4 patients experiencing meaningful improvement, while antibiotics have no role and should never be prescribed. 1

First-Line Treatment Approach

Combination Therapy (Preferred for Multiple Symptoms)

• Antihistamine-decongestant-analgesic combinations are the most effective single intervention for adults and older children with common cold, providing general benefit across multiple symptoms 2, 1
• These combinations should NOT be used in children younger than 4 years due to lack of effectiveness and potential harm 2, 3
• The evidence specifically supports older antihistamine-decongestant combinations, not newer non-sedating antihistamines 2

Single-Agent Therapy (For Targeted Symptoms)

For nasal congestion:

• Oral decongestants (pseudoephedrine): 60 mg every 4-6 hours, maximum 240 mg/24 hours in adults; 30 mg every 4-6 hours in children 6-11 years 4
• Topical nasal decongestants provide small but positive effects on subjective nasal congestion 2
• Critical caveat: Limit use to 3 days maximum to avoid rebound congestion (rhinitis medicamentosa) 2

For pain, headache, and fever:

• NSAIDs (ibuprofen, naproxen): Effective for headache, ear pain, muscle/joint pain, malaise, and sneezing symptoms 2, 1
• Acetaminophen (paracetamol): May help nasal obstruction and rhinorrhea but does NOT improve sore throat, malaise, sneezing, or cough 2, 5
• NSAIDs are generally preferred over acetaminophen for broader symptom coverage 2

For rhinorrhea (runny nose):

• Ipratropium bromide nasal spray: Effective for reducing rhinorrhea but has no effect on nasal congestion 2, 1
• Side effects include nasal dryness but are generally well-tolerated and self-limiting 2

For cough:

• Central cough suppressants (codeine, dextromethorphan) are NOT recommended for cough due to upper respiratory infections—they have limited efficacy and no proven benefit 2
• Dextromethorphan dosing (if used despite limited evidence): Adults 10 mL every 12 hours; children 6-12 years 5 mL every 12 hours; children 4-6 years 2.5 mL every 12 hours 6
• Important distinction: These agents may work for chronic bronchitis but NOT for common cold 2

Adjunctive Therapies with Evidence

Zinc lozenges:

• Dosage: ≥75 mg/day of zinc acetate or zinc gluconate started within 24 hours of symptom onset 2, 1
• Significantly reduces cold duration when used throughout the illness 2
• Must be started early—ineffective if symptoms already prolonged 7
• Side effects include bad taste and nausea 1

Vitamin C:

• May be worthwhile to try on individual basis given consistent effect on duration/severity, low cost, and safety 2
• More effective as prophylaxis than treatment 3, 8

Nasal saline irrigation:

• Provides modest benefit for symptom relief, particularly in children 2, 1
• Safe and can be used as adjunct therapy 2

Treatments to AVOID

Antibiotics:

• No evidence of benefit for common cold in children or adults 2, 1
• Associated with significant adverse effects and contribute to antimicrobial resistance 2, 7
• Only 0.5-2% of viral upper respiratory infections develop bacterial complications 7

Intranasal corticosteroids:

• No evidence supporting use for common cold symptom relief 2
• May be considered only if symptoms persist >10 days suggesting post-viral rhinosinusitis 7

Antihistamines alone:

• Limited short-term benefit (days 1-2 only) in adults 2
• No clinically significant effect on nasal obstruction, rhinorrhea, or sneezing 2

Over-the-counter cough and cold medications:

• NOT recommended until proven effective in randomized controlled trials, except older antihistamine-decongestant combinations 2
• Zinc preparations are NOT recommended for acute cough 2

Echinacea:

• Most products are not effective; some show possible weak benefit of questionable clinical relevance 2

Steam/heated humidified air:

• No proven benefits or harms 2

Clinical Algorithm

1. Assess symptom severity and patient age

   • Children <4 years: Avoid OTC cold medications; consider honey (if >1 year), saline irrigation, or topical vapor rub 3, 9
   • Children 4-11 years: Can use single agents at reduced doses 4
   • Adults and children ≥12 years: Full treatment options available

2. For multiple symptoms: Start combination antihistamine-decongestant-analgesic product 1

3. For single dominant symptom:

   • Nasal congestion → Short-term decongestant (≤3 days) 2
   • Rhinorrhea → Ipratropium bromide nasal spray 2, 1
   • Pain/fever → NSAIDs preferred over acetaminophen 2

4. Add zinc lozenges (≥75 mg/day) if within 24 hours of onset 2, 1

5. Consider saline irrigation as safe adjunct 2, 1

Critical Pitfalls to Avoid

• Never prescribe antibiotics for uncomplicated cold symptoms, even if prolonged beyond 7 days 2, 7
• Limit topical decongestants to 3 days maximum to prevent rebound congestion 2
• Do not use cough suppressants for URI-related cough—evidence shows no benefit 2
• Manage patient expectations: Cold symptoms typically last up to 14 days; 25% of patients have symptoms for 2 weeks 7
• Zinc timing is critical: Only effective if started within 24 hours of symptom onset 7

When to Reassess for Bacterial Infection

Consider bacterial rhinosinusitis only if ≥3 of these criteria present 7:

• Discolored (purulent) nasal discharge
• Severe unilateral facial pain
• Fever >38°C (100.4°F), especially after day 3
• "Double sickening" (improvement then worsening)
• Elevated inflammatory markers