Best Treatment for the Viral Cold
The common cold requires only symptomatic management with combination antihistamine-decongestant-analgesic products providing the most effective relief (1 in 4 patients experience significant improvement), while antibiotics should never be prescribed as they provide no benefit and cause harm. 1, 2
What NOT to Do
- Never prescribe antibiotics for the common cold – they are ineffective, increase adverse effects (number needed to harm = 8), and contribute to antimicrobial resistance 1, 2
- Avoid newer "non-sedating" antihistamines alone – they are relatively ineffective for cold symptoms 1
- Do not use intranasal corticosteroids for acute cold symptoms 2
- Limit topical nasal decongestants to 3-5 days maximum to prevent rhinitis medicamentosa (rebound congestion) 1, 2
First-Line Symptomatic Treatment
Combination products are superior to single agents:
- Use combination antihistamine-decongestant-analgesic products – these provide the best symptom relief with odds ratio of treatment failure 0.47 (number needed to treat = 5.6) 2
- Effective combination: first-generation antihistamine (like brompheniramine) + sustained-release pseudoephedrine + analgesic 1, 2
- These combinations work better than any single component alone 1, 2
Individual Symptom Management
For pain, fever, and general malaise:
- NSAIDs (ibuprofen 400-800 mg every 6-8 hours) are effective for headache, ear pain, muscle/joint pain, malaise, and also improve sneezing 2, 3
- Acetaminophen/paracetamol helps nasal obstruction and rhinorrhea but does not improve other symptoms as effectively 2, 3
For nasal congestion:
- Oral decongestants (pseudoephedrine or phenylephrine) provide modest benefit 2
- Topical nasal decongestants are effective but strictly limit to 3-5 days 1, 2
For runny nose:
- Ipratropium bromide nasal spray effectively reduces rhinorrhea (though not congestion) 1, 2
- Nasal saline irrigation provides modest relief and helps dilute secretions 2
For cough:
- Dextromethorphan 60 mg for maximum effect (standard OTC doses likely subtherapeutic) 2, 4
- Menthol inhalation provides short-lived relief 2
- Honey and lemon is recommended as simple, inexpensive home remedy 2
- Avoid opiate antitussives due to significant adverse effects without clear superiority 2
Time-Sensitive Adjunctive Therapy
Zinc lozenges – ONLY if started within 24 hours of symptom onset:
- Use zinc acetate or zinc gluconate ≥75 mg/day – significantly reduces cold duration but ONLY if started within 24 hours 1, 2
- No benefit if symptoms already established beyond 24 hours 1, 2
- Potential side effects: bad taste and nausea 1
Expected Timeline and When to Reassess
Normal cold duration:
- Symptoms typically last 7-10 days 2, 4
- Up to 25% of patients continue with cough and nasal discharge for 14 days – this is normal and does not indicate bacterial infection 1, 2
- Patients should follow up if symptoms worsen or exceed expected recovery time 1
When to consider bacterial complication (after 10+ days):
- Only 0.5-2% of viral colds develop bacterial complications 2
- Suspect bacterial sinusitis only if ≥3 of these criteria: purulent nasal discharge, severe local pain, fever >38°C, "double sickening" pattern (improvement then worsening), elevated inflammatory markers 2
- Common pitfall: 87% of patients show sinus abnormalities on CT during viral colds that resolve without antibiotics – do not diagnose bacterial sinusitis in first 10 days 1
Red Flags Requiring Further Evaluation
- Fever >38°C persisting beyond 3 days or appearing after initial improvement 2
- Severe unilateral facial pain 2
- "Double sickening" pattern (initial improvement followed by worsening after 5 days) 1, 2
- Hemoptysis (any amount) 2
- Acute breathlessness 2