What are the recommended treatments for the common cold?

Recommended Treatments for the Common Cold

For adults and older children with the common cold, use combination antihistamine-analgesic-decongestant products as first-line therapy for significant symptom relief, with approximately 1 in 4 patients experiencing meaningful improvement. 1, 2

First-Line Symptomatic Treatment

Combination therapy is superior to single agents for managing multiple cold symptoms simultaneously. 1, 2

• Antihistamine-decongestant-analgesic combinations provide the most comprehensive relief for nasal congestion, rhinorrhea, headache, and malaise in adults and older children. 3, 1, 2
• First-generation antihistamines (brompheniramine or dexbrompheniramine) combined with pseudoephedrine effectively reduce congestion, postnasal drainage, sneezing, and throat clearing. 1, 4
• Important caveat: These combination products have no proven effectiveness in young children (under 4 years), and should not be used in this age group due to potential harm without benefit. 3, 5

Targeted Single-Symptom Management

When patients have isolated symptoms or prefer single agents:

For Nasal Congestion

• Oral decongestants (pseudoephedrine) or topical nasal decongestants (oxymetazoline) provide small but positive effects on nasal congestion. 1, 2, 6
• Critical warning: Limit decongestant use to short-term only (maximum 3 days for topical agents) to prevent rebound congestion. 3, 1, 2

For Rhinorrhea (Runny Nose)

• Ipratropium bromide nasal spray is highly effective for reducing rhinorrhea, though it does not improve nasal congestion. 1, 2, 5
• Minor side effects include nasal dryness. 2

For Pain, Headache, and Malaise

• NSAIDs (ibuprofen or naproxen) effectively relieve headache, ear pain, muscle/joint pain, malaise, and also improve sneezing. 1, 2, 4
• Acetaminophen (paracetamol) may help relieve nasal obstruction and rhinorrhea, but does not improve sore throat, malaise, sneezing, or cough. 2, 4, 7

Evidence-Based Adjunctive Therapies

Zinc Lozenges (Strongest Evidence for Duration Reduction)

• Zinc acetate or gluconate lozenges at ≥75 mg/day significantly reduce cold duration if started within 24 hours of symptom onset. 3, 1, 2
• Must be continued throughout the cold at this dose for effectiveness. 3
• Common pitfall: Missing the 24-hour window eliminates the benefit—counsel patients to start immediately at symptom onset. 1, 2
• Potential side effects include bad taste and nausea. 2

Vitamin C

• Given its consistent effect on duration and severity, low cost, and safety profile, vitamin C may be worthwhile for patients to test on an individual basis. 3, 1, 2
• Prophylactic vitamin C modestly reduces cold symptom duration. 5

Nasal Saline Irrigation

• Provides modest symptom relief without drug interactions or significant adverse effects. 1, 2
• Particularly beneficial in children. 2, 5

Herbal Medicines (Excluding Echinacea)

• BNO1016 (Sinupret), Cineole, and Andrographis paniculata SHA-10 extract have significant impact on common cold symptoms without important adverse events. 3, 2, 4
• These represent reasonable alternatives for patients seeking herbal options. 3

Treatments to AVOID (Ineffective or Harmful)

Antibiotics

• No benefit whatsoever for uncomplicated common cold. 1, 2, 4
• Contribute to antimicrobial resistance and cause significant adverse effects. 1, 2, 4
• Only 0.5-2% of viral upper respiratory infections develop bacterial complications. 1, 4
• Major pitfall: Avoid prescribing antibiotics based on symptom duration alone or patient/family pressure. 1

Intranasal Corticosteroids

• Provide no symptomatic relief for acute common cold symptoms. 3, 1, 2, 4
• This contrasts with their effectiveness in allergic rhinitis and post-viral rhinosinusitis. 3

Non-Sedating Antihistamines

• Newer antihistamines (loratadine, cetirizine, fexofenadine) are ineffective for common cold symptoms. 1, 4, 5
• Only first-generation antihistamines in combination products show benefit. 1, 4

Echinacea

• Most Echinacea products are not effective based on Cochrane systematic review of 24 trials with 4,631 participants. 3, 2, 4
• Some products showed possible weak benefit, but effects are of questionable clinical relevance. 3

Homeopathic Products

• No significant benefit compared to placebo on infection recurrence or cure rates. 3

Cough Suppressants

• Central cough suppressants (codeine, dextromethorphan) have limited efficacy for URI-related cough. 1, 8
• Codeine has not been shown to effectively treat cough caused by common cold. 8

Steam/Heated Humidified Air

• Current evidence shows no benefits or harms. 3

Clinical Course and When to Reassess

Normal Duration

• Cold symptoms typically last 7-10 days, with approximately 25% of patients having symptoms for up to 14 days—this is normal and does not indicate bacterial infection. 1, 2, 4

Red Flags Requiring Reassessment

• Symptoms persisting >10 days without any improvement classify as post-viral rhinosinusitis. 1, 4
• Symptoms that worsen after initial improvement. 1
• Development of high fever. 1

Special Population Considerations

Young Children (Under 4 Years)

• Do not use over-the-counter cough and cold medications due to potential harm without proven benefit. 3, 5
• Safe options include vapor rub, zinc sulfate, buckwheat honey, and nasal saline irrigation. 5

Elderly Patients

• Monitor for CNS side effects (confusion, dizziness) and gastrointestinal symptoms when using combination products. 1
• Patients with declining renal function may require monitoring for drug clearance and increased risk of adverse effects. 1

Lactating Women

• Acetaminophen, NSAIDs, and combination products are appropriate options. 4
• Zinc lozenges and vitamin C are safe adjunctive therapies. 4