Treatment of Cough and Colds
For acute cough associated with the common cold, prescribe a first-generation antihistamine/decongestant combination (such as brompheniramine with sustained-release pseudoephedrine) or naproxen as first-line therapy. 1
First-Line Pharmacological Treatment
Recommended Medications
First-generation antihistamine/decongestant combinations are the most effective treatment for acute cough, postnasal drip, and throat clearing associated with the common cold, with substantial evidence supporting their use. 1
Naproxen (a nonsteroidal anti-inflammatory drug) can be administered to help decrease cough by reducing inflammation caused by the viral infection. 1
Dextromethorphan is the preferred antitussive agent when cough suppression is needed, with maximum effect at 60 mg dosing and a superior safety profile compared to codeine. 2, 3 The FDA indicates it temporarily relieves cough due to minor throat and bronchial irritation. 4
Medications to Avoid
Newer-generation nonsedating antihistamines are ineffective for reducing cough in the common cold and should not be used. 1
Over-the-counter combination cold medications should not be used unless they contain older antihistamine/decongestant ingredients, as they have not been proven effective in randomized controlled trials. 1
Zinc-containing preparations are not recommended due to conflicting evidence and lack of proven benefit. 1
Codeine and other opioid antitussives offer no efficacy advantage over dextromethorphan but carry significantly greater adverse effects. 2, 3
Antibiotic Use: Critical Pitfall
Antibiotics should NOT be prescribed for acute cough from the common cold or acute bronchitis. 1 This is one of the most important clinical decisions to avoid:
Bacterial sinusitis cannot be accurately diagnosed during the first week of symptoms, as viral infections cause sinus imaging abnormalities in 87% of patients that resolve without antibiotics. 1
Clinical judgment is required, but specificity for bacterial infection only increases after more than one week from symptom onset. 1
Green or yellow sputum alone does not indicate bacterial infection requiring antibiotics in the first week. 5
Special Considerations and Contraindications
Patient Screening Before Prescribing
Check for contraindications to first-generation antihistamine/decongestant combinations: 1, 3
- Glaucoma
- Benign prostatic hypertrophy
- Uncontrolled hypertension
- Renal failure (for naproxen)
- Gastrointestinal bleeding risk (for naproxen)
- Congestive heart failure
Alternative Options When First-Line is Contraindicated
Ipratropium bromide (inhaled anticholinergic) is the only inhaled agent recommended for cough suppression in upper respiratory infections. 1, 2
Simple home remedies like honey and lemon mixtures are recommended as cost-effective first-line approaches without adverse effects. 2, 3
Duration and Natural History
Approximately 25% of patients continue to have cough, postnasal drip, and throat clearing at day 14 even with treatment. 1
If cough persists beyond 3 weeks, it should be evaluated and managed as chronic cough rather than continuing symptomatic treatment. 1, 3
Practical Prescribing Algorithm
Rule out serious conditions (pneumonia, congestive heart failure, pulmonary embolism) by checking for fever with systemic illness, abnormal chest findings, tachycardia, tachypnea, or hemoptysis. 3
Screen for contraindications to first-generation antihistamine/decongestant combinations and NSAIDs. 1, 3
Prescribe first-line therapy:
Avoid antibiotics unless symptoms persist beyond one week with worsening rather than improvement. 1
Reassess at 3 weeks - if cough persists, pursue diagnostic workup for chronic cough rather than continued empiric suppression. 1, 3