What are the recommended treatments for the common cold?

Treatment of the Common Cold

For adults and older children with the common cold, use combination antihistamine-analgesic-decongestant products as first-line therapy, which provide significant symptom relief in approximately 1 in 4 patients, while avoiding antibiotics entirely as they provide no benefit and cause harm. 1, 2

First-Line Symptomatic Treatment

Combination Products (Preferred)

• Combination antihistamine-analgesic-decongestant products are superior to single agents with an odds ratio of treatment failure of 0.47 (95% CI 0.33-0.67; number needed to treat 5.6). 1, 2
• Effective combinations include first-generation antihistamines (such as brompheniramine) plus sustained-release pseudoephedrine plus an analgesic. 2
• These products address multiple symptoms simultaneously and have the strongest evidence for overall symptom relief. 1

Single-Agent Options for Targeted Symptoms

For nasal congestion:

• Oral decongestants (pseudoephedrine or phenylephrine) provide modest benefit for nasal congestion. 1, 3
• Topical nasal decongestants are effective but must be limited to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa). 2
• Critical pitfall: Prolonged decongestant use leads to worsening congestion requiring medical intervention. 1

For pain, fever, and multiple symptoms:

• NSAIDs (ibuprofen 400-800 mg every 6-8 hours) are effective for headache, ear pain, muscle/joint pain, malaise, and also improve sneezing. 1, 2
• Acetaminophen/paracetamol may help nasal obstruction and rhinorrhea but does not improve sore throat, malaise, sneezing, or cough. 1, 4

For rhinorrhea (runny nose):

• Ipratropium bromide nasal spray effectively reduces rhinorrhea but does not improve nasal congestion. 1, 2
• May cause minor side effects like nasal dryness. 1

For cough:

• Dextromethorphan (60 mg for maximum effect) suppresses acute cough, though standard over-the-counter doses are likely subtherapeutic. 2, 5
• Honey and lemon is recommended as a simple, inexpensive home remedy with patient-reported benefit. 2
• Menthol inhalation provides acute but short-lived cough suppression. 2

Evidence-Based Adjunctive Therapies

Zinc lozenges (time-sensitive):

• Zinc acetate or zinc gluconate lozenges at ≥75 mg/day significantly reduce cold duration BUT only if started within 24 hours of symptom onset. 6, 1
• No benefit if symptoms are already established beyond 24 hours. 1, 2
• Potential side effects include bad taste and nausea. 1, 2

Nasal saline irrigation:

• Provides modest symptom relief, particularly beneficial in children. 6, 1, 2
• Helps dilute secretions and facilitate elimination. 2

Vitamin C:

• May be worth trying on an individual basis given consistent effect on duration and severity, low cost, and safety profile. 6, 1
• Evidence shows modest benefit when used regularly. 6

Herbal medicines:

• Some herbal medicines like BNO1016 (Sinupret), Cineole, and Andrographis paniculata SHA-10 extract have significant impact on symptoms without important adverse events. 6

What Does NOT Work (Avoid These)

Antibiotics:

• Antibiotics have no benefit for uncomplicated common cold, provide no effect on cure or duration, cause more adverse events, and contribute to antimicrobial resistance. 6, 1, 2, 7
• This is true even when symptoms are prolonged beyond 7 days. 2, 8

Intranasal corticosteroids:

• Currently, there is no evidence to support the use of intranasal corticosteroids for symptomatic relief from the common cold. 6, 1

Echinacea:

• Most Echinacea products are not effective, with potential effects of questionable clinical relevance. 6

Steam/heated humidified air:

• Current evidence does not show any benefits or harms. 6

Non-sedating antihistamines (newer generation):

• Ineffective for cold symptoms. 2

Pediatric-Specific Considerations

• Over-the-counter cough and cold medications should not be used in children younger than four years due to potential for harm and no benefits. 9
• Acetaminophen/paracetamol for fever and pain is appropriate. 1, 2
• Products that improve symptoms in children include vapor rub, zinc sulfate, Pelargonium sidoides extract, buckwheat honey (for children one year and older), and nasal saline irrigation. 9, 10

When Symptoms Persist Beyond 10 Days

• Approximately 25% of patients continue with cough and nasal discharge up to 14 days—this is normal and does not indicate bacterial infection. 2, 8
• Symptoms persisting >10 days without improvement classify as post-viral rhinosinusitis. 2, 8
• Intranasal corticosteroids may be beneficial for post-viral rhinosinusitis symptoms. 2, 8
• Continue symptomatic treatment with combination products. 8

Warning signs requiring medical evaluation:

• Fever >38°C (100.4°F) persisting beyond 3 days or appearing after initial improvement. 2, 8
• Severe unilateral facial pain. 2, 8
• "Double sickening" pattern (initial improvement followed by worsening). 2, 8
• Hemoptysis (any amount). 2

Bacterial rhinosinusitis criteria:

• Only suspect bacterial infection if at least 3 of 5 criteria are present: discolored (purulent) nasal discharge, severe local pain, fever >38°C, "double sickening" pattern, or elevated inflammatory markers. 2, 8
• Key point: Only 0.5-2% of viral upper respiratory infections develop bacterial complications. 2, 8

Treatment Algorithm

For mild symptoms:

• Start with single-agent therapy: short-term decongestant (oral or topical) for nasal congestion, acetaminophen or NSAIDs for pain/fever, ipratropium bromide nasal spray for rhinorrhea. 1

For multiple symptoms:

• Use combination antihistamine-analgesic-decongestant products. 1, 2

Consider adding:

• Zinc lozenges (≥75 mg/day) if within 24 hours of symptom onset. 1, 2
• Saline nasal irrigation for additional symptom relief. 1, 2

Patient Education

• Cold symptoms typically last 7-10 days, with up to 25% experiencing symptoms for 14 days. 2, 8
• The illness is self-limiting and viral—antibiotics will not help. 2
• Hand hygiene is the best way to prevent transmission of cold viruses. 9, 10