What are the treatment options for a person with a cold and cough?

Treatment for Cold and Cough

For acute cough and cold symptoms, treat with a first-generation antihistamine/decongestant combination (brompheniramine with sustained-release pseudoephedrine) plus naproxen, as this is the only over-the-counter regimen with substantial evidence for symptom relief. 1

First-Line Pharmacologic Treatment

Recommended Medications

• First-generation antihistamine/decongestant combinations (such as brompheniramine with sustained-release pseudoephedrine) provide substantial benefit for acute cough, post-nasal drip, and throat clearing associated with the common cold 1, 2
• Naproxen can be added to help decrease cough in this setting 1
• Dextromethorphan (60 mg for maximum cough reflex suppression) is a non-sedating option that has demonstrated efficacy in meta-analyses for cough suppression 3, 4
  • FDA-approved to temporarily relieve cough due to minor throat and bronchial irritation 4
  • Provides prolonged effect at the 60 mg dose 3

Medications to Avoid

• Newer-generation non-sedating antihistamines are ineffective for reducing cough and should not be used 1, 2
• Codeine and pholcodine have no greater efficacy than dextromethorphan but carry a much greater adverse side effect profile and are not recommended 3
• Over-the-counter combination cold medications (except the older antihistamine-decongestant combination noted above) are not recommended until randomized controlled trials prove effectiveness 1
• Zinc preparations are not recommended for acute cough due to the common cold 1
• Albuterol is not recommended for acute cough not due to asthma 1

Non-Pharmacologic and Adjunctive Measures

Simple Effective Interventions

• Honey and lemon mixtures are the simplest, cheapest, and often effective first approach for productive cough 3
• Adequate hydration helps thin secretions and makes coughs more productive 3
• Menthol inhalation (via crystals, capsules, or lozenges) provides acute, short-lived cough suppression through cold and menthol sensitive receptors 3

Behavioral Measures

• Simple voluntary suppression of cough may be sufficient to reduce cough frequency in many cases 3
• Stop smoking as it worsens cough and respiratory symptoms 3
• Proper cough hygiene (handkerchief use, hand washing) prevents spreading infection 3

Important Clinical Considerations

Antibiotic Use

• Do not diagnose bacterial sinusitis during the first week of cold symptoms, as viral rhinosinusitis causes sinus abnormalities in 87% of patients that resolve without antibiotics in 79% of cases 1
• Clinical judgment is required to decide when to institute antibiotic therapy, as specificity for bacterial infection increases with time from symptom onset 1
• Antibiotics are not helpful for productive cough due to viral infections, even when phlegm is present 3

Natural History and Expectations

• Approximately 25% of patients continue to have symptoms of cough, post-nasal drip, and throat clearing at day 14, even with improvement 1
• This correlates with persistent anatomic abnormalities seen on imaging in 21% of patients at days 13-20 1
• Most productive coughs are self-limiting and will resolve without specific treatment, particularly when caused by viral upper respiratory infections 3

Red Flags Requiring Medical Attention

Seek immediate evaluation if the patient has: 3

• Coughing up blood
• Breathlessness
• Prolonged fever with feeling unwell
• Underlying conditions (COPD, heart disease, diabetes, asthma)
• Recent hospitalization
• Symptoms persisting beyond three weeks

Special Populations

Nocturnal Cough

• First-generation antihistamines with sedative properties may be particularly suitable for nocturnal cough due to their sedating effect 3

Children

• Exercise caution with dosing, as some preparations contain multiple ingredients like paracetamol that could lead to overdosage 3
• Consider pediatric formulations when available 5