What is the recommended symptomatic treatment for cough and congestion due to an acute viral illness?

Symptomatic Treatment for Cough and Congestion Due to Acute Viral Illness

For acute viral cough and congestion, use a first-generation antihistamine/decongestant combination (such as diphenhydramine plus pseudoephedrine) as first-line therapy, or alternatively naproxen, unless contraindications exist. 1

First-Line Pharmacologic Options

Antihistamine-Decongestant Combinations

• First-generation antihistamine/decongestant combinations are strongly recommended by the American College of Chest Physicians for acute cough from the common cold 1
• These combinations were significantly more effective than placebo in reducing cough symptoms (p<0.01) 2
• Newer-generation nonsedating antihistamines should NOT be used as they are ineffective for acute viral cough 1
• Contraindications include glaucoma, benign prostatic hypertrophy, uncontrolled hypertension, renal failure, and congestive heart failure 1

NSAIDs

• Naproxen (Naprosyn, Aleve) is strongly recommended as an alternative to antihistamine-decongestant combinations 1
• Contraindications include gastrointestinal bleeding, renal failure, and congestive heart failure 1

Analgesics for Symptom Relief

• Acetaminophen or ibuprofen should be given for pain, fever, or general discomfort associated with viral illness 1, 3
• These provide symptomatic relief but do not specifically target cough mechanisms 3

Nasal Saline Irrigation

• Nasal saline (physiologic or hypertonic) provides minor improvements in nasal symptom scores with minimal risk of adverse effects 1, 3
• This is palliative and cleansing, appropriate for congestion relief 1

Topical Intranasal Corticosteroids

• May be recommended for symptomatic relief of congestion, though benefits are modest 1
• The American Academy of Otolaryngology-Head and Neck Surgery considers this an option for viral rhinosinusitis 1

Antitussive Agents: Limited Role

Dextromethorphan

• May provide modest effects on cough severity and duration in acute bronchitis 4, 5
• A single meta-analysis showed suppression of acute cough, but maximum effect requires 60mg dosing (higher than typical over-the-counter preparations) 1
• Less effective for early cough from viral upper respiratory infections 6
• FDA-approved as a cough suppressant 7

Codeine and Other Opiates

• Codeine is NOT recommended as it has not been shown to effectively treat cough caused by the common cold or acute viral respiratory infections 6, 2
• Codeine was no more effective than placebo in reducing cough symptoms 2
• Opiate antitussives have significant adverse side effect profiles without greater efficacy than dextromethorphan 1
• Should be reserved as last-line option only when other measures fail 6

Menthol

• Menthol by inhalation suppresses the cough reflex acutely but effect is short-lived 1
• May be prescribed as menthol crystals or proprietary capsules 1

Agents NOT Recommended

Guaifenesin (Expectorant)

• The American College of Chest Physicians states mucokinetic agents including guaifenesin are NOT recommended for acute bronchitis because there is no consistent favorable effect on cough 6
• FDA-approved to help loosen phlegm and thin bronchial secretions 8, but clinical evidence does not support routine use 6
• Evidence is conflicting: one study showed 75% found it helpful vs 31% placebo, while another showed no difference 2

Beta-Agonists

• Should NOT be routinely used for cough in acute viral illness 4
• May be considered only if wheezing is present 6, 4

Over-the-Counter Combination Products

• Most OTC combination cold medications are NOT recommended unless they contain older antihistamine/decongestant ingredients 1
• A Cochrane review concluded there is no good evidence for or against the effectiveness of OTC medicines in acute cough 2

What NOT to Prescribe

Antibiotics

• Antibiotics are NOT indicated for acute viral cough as they are ineffective for viral illness and do not provide direct symptom relief 1, 4
• Antibiotics should only be considered when clinical features suggest bacterial infection (symptoms persisting >10 days without improvement, severe symptoms) 3
• The presence of purulent or discolored nasal discharge does NOT indicate bacterial infection and is not an indication for antibiotics 1, 4

Special Consideration: Influenza

• For outpatient adults with acute cough and suspected influenza, initiate antiviral treatment (neuraminidase inhibitors per CDC guidance) within 48 hours of symptom onset 1, 4
• Antiviral treatment may decrease antibiotic usage, hospitalization, and improve outcomes 1

Patient Education

• Inform patients that viral cough typically lasts 10-14 days after the office visit, even with treatment 3, 4
• Symptoms in acute viral rhinosinusitis typically peak within 3 days then gradually decline and resolve within 10-14 days 1
• Patient satisfaction depends more on physician-patient communication than whether medications are prescribed 3, 4

Common Pitfalls to Avoid

• Do not diagnose "acute bronchitis" when the common cold has not been ruled out, as this leads to inappropriate antibiotic prescribing 1
• Do not prescribe newer-generation nonsedating antihistamines—they are ineffective for acute viral cough 1
• Avoid continuous use of topical decongestants beyond 3-5 days to prevent rebound congestion 1
• Do not assume purulent sputum indicates bacterial infection requiring antibiotics 1, 4