What are the treatment options for a cold?

Treatment of the Common 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 are never indicated for uncomplicated cases. 1

What NOT to Do

• Never prescribe antibiotics for uncomplicated common cold—they provide no benefit for symptom duration or prevention of complications, even in patients with risk factors, and contribute to antimicrobial resistance 2, 1, 3
• Avoid corticosteroids entirely—they provide no symptomatic relief and increase infection risk 4
• Do not use intranasal corticosteroids for acute cold symptoms 3
• Avoid over-the-counter cough and cold medications in children under 4 years due to potential harm without benefit 5

First-Line Symptomatic Treatment

Combination Products (Most Effective)

• Use combination antihistamine-decongestant-analgesic products as first-line therapy—these provide superior relief compared to single agents with odds ratio of treatment failure 0.47 (95% CI 0.33-0.67; number needed to treat 5.6) 1, 3
• Specific effective combination: first-generation antihistamine (brompheniramine) plus sustained-release pseudoephedrine for congestion and rhinorrhea 4, 1

Individual Symptom-Targeted Therapies

For nasal congestion:

• Oral decongestants (pseudoephedrine or phenylephrine) provide modest benefit 1, 3
• Topical nasal decongestants are effective but limit use to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa) 1, 3

For rhinorrhea (runny nose):

• Ipratropium bromide nasal spray effectively reduces rhinorrhea but does not improve congestion 2, 1, 3
• Paracetamol/acetaminophen may help nasal obstruction and rhinorrhea but does not improve other symptoms 2, 3, 6

For pain, headache, fever:

• NSAIDs (ibuprofen 400-800 mg every 6-8 hours) are effective for headache, ear pain, muscle/joint pain, malaise, and also improve sneezing 2, 4, 1, 3
• Acetaminophen/paracetamol for fever and pain, particularly in children and pregnant women 1, 6

For cough:

• Dextromethorphan (60 mg for maximum effect) suppresses acute cough, though standard over-the-counter doses are likely subtherapeutic 1, 7
• Honey and lemon is recommended as a simple, inexpensive home remedy with patient-reported benefit 1
• Avoid opiate antitussives due to significant adverse effects without clear superiority 1

Evidence-Based Adjunctive Therapies

Zinc lozenges (critical timing requirement):

• Use zinc acetate or zinc gluconate lozenges at ≥75 mg/day ONLY if started within 24 hours of symptom onset—this significantly reduces cold duration 2, 4, 1, 3
• No benefit if symptoms already established beyond 24 hours 1, 3
• Potential side effects include bad taste and nausea 1, 3

Nasal saline irrigation:

• Provides modest symptom relief, particularly beneficial in children 2, 4, 1, 3
• Helps dilute secretions and facilitate elimination 1

Vitamin C:

• May be worthwhile to test on an individual basis given consistent effect on duration and severity, low cost, and safety 2, 3

Expected Clinical Course and Patient Education

• Cold symptoms typically last 7-10 days, with up to 25% of patients having symptoms for 14 days—this is normal and does not indicate bacterial infection 2, 1, 3
• The illness is self-limiting and viral 2, 1
• Symptoms are due to the host's immune response (cytokine release, vascular leak) rather than tissue destruction 8

When to Suspect Bacterial Complications

Only consider antibiotics if bacterial complication develops (not for the cold itself) 2:

• Fever >38°C (100.4°F) persisting beyond 3 days or appearing after initial improvement 2, 4, 1
• Severe unilateral facial pain suggesting bacterial sinusitis 1
• "Double sickening" pattern (initial improvement followed by worsening) 4, 1
• Acute otitis media, sinusitis with purulent discharge 2

Critical pitfall: Do not diagnose bacterial sinusitis in the first 10 days of symptoms—87% of patients show sinus abnormalities on CT during viral colds that resolve without antibiotics 1

Only suspect bacterial infection if at least 3 of 5 criteria present: discolored nasal discharge, severe local pain, fever >38°C, "double sickening" pattern, elevated inflammatory markers 4, 1

Special Populations

Children:

• Acetaminophen/paracetamol for fever and pain 1
• Nasal saline irrigation particularly beneficial 1
• Avoid over-the-counter cough and cold medications in children under 4 years 5

Pregnant women:

• Acetaminophen/paracetamol is first-line for pain and fever 1

Ineffective Therapies to Avoid

• Non-sedating antihistamines (newer generation) are ineffective 1
• Steam/heated humidified air has no proven benefits 2, 3
• Echinacea products do not provide significant benefits 2, 3
• Codeine has not been shown to effectively treat cold-related cough 9