What are the recommended medications for treating the common cold?

Common Cold Medication Recommendations

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

First-Line Treatment Approach

Combination therapy is superior to single agents when multiple cold symptoms are present (nasal congestion, rhinorrhea, headache, malaise). 1, 2

• First-generation antihistamines (brompheniramine or dexbrompheniramine) combined with decongestants like pseudoephedrine effectively address congestion, postnasal drainage, sneezing, and throat clearing 1
• These combination products provide the most comprehensive symptom relief based on Level 1a evidence from the European Position Paper on Rhinosinusitis 3

Targeted Single-Symptom Treatment

For Nasal Congestion

• Oral pseudoephedrine or topical oxymetazoline have small positive effects on nasal congestion 1, 2
• Critical caveat: Limit decongestants to short-term use only (3-5 days maximum) to avoid rebound congestion 3, 2

For Rhinorrhea (Runny Nose)

• Ipratropium bromide nasal spray is highly effective for reducing rhinorrhea, though it does not improve nasal congestion 3, 1, 2
• Minor side effects include nasal dryness and irritation, which are generally well-tolerated 3

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
• Paracetamol (acetaminophen) may help relieve nasal obstruction and rhinorrhea but does not improve other cold symptoms like sore throat or malaise 2, 5

Evidence-Based Adjunctive Therapies

Zinc Lozenges (Time-Sensitive)

• Zinc acetate or gluconate lozenges at ≥75 mg/day significantly reduce cold duration if started within 24 hours of symptom onset 3, 1
• This is a critical 24-hour window—after this period, zinc loses its effectiveness 1, 2
• Continue zinc throughout the duration of the cold at this dose 3

Nasal Saline Irrigation

• Provides modest symptom relief without drug interactions or significant adverse effects 3, 1, 2
• Particularly beneficial in children 3

Vitamin C

• May provide individual benefit given its consistent effect on duration and severity, low cost, and safety profile 3, 1
• Worth trying on an individual basis, though effects are modest 2

Treatments to AVOID

Antibiotics

• No benefit whatsoever for uncomplicated common cold 3, 1, 2, 6
• Contribute to antimicrobial resistance with significant adverse effects 1, 2, 6
• Only 0.5-2% of viral upper respiratory infections develop bacterial complications 1

Intranasal Corticosteroids

• No evidence supporting their use for common cold symptomatic relief 3, 1, 2, 6
• Should not be prescribed for this indication 6

Non-Sedating Antihistamines

• Loratadine, cetirizine, and fexofenadine are ineffective for common cold symptoms 1
• Only first-generation antihistamines in combination products show benefit 1, 2

Echinacea

• Most Echinacea products are not effective based on Cochrane systematic review of 24 trials 3
• Any potential effects are of questionable clinical relevance 3

Other Ineffective Treatments

• Steam or heated humidified air shows no benefits 3, 2
• Homeopathic products show no significant benefit 3
• Central cough suppressants (codeine, dextromethorphan) have limited efficacy 1

Special Population Considerations

Children Under 4 Years

• Over-the-counter cough and cold medications should NOT be used in children younger than 4 years 4
• No evidence of effectiveness in young children 3
• Safe options for children include: honey (age ≥1 year), nasal saline irrigation, and topical vapor rub 4, 7

Elderly Patients

• Monitor for CNS side effects (confusion, dizziness) with combination products 1
• Watch for declining renal function affecting drug clearance 1
• Increased risk of adverse effects requires closer monitoring 1

Clinical Course and Red Flags

• Cold symptoms typically last 7-10 days, with 25% of patients having symptoms up to 14 days—this is normal and does not indicate bacterial infection 1
• Reassess if: symptoms worsen after initial improvement, persist beyond 10 days without any improvement, or high fever develops 1
• Symptoms persisting more than 10 days without improvement classify as post-viral rhinosinusitis 1

Common Pitfalls to Avoid

• Inappropriate antibiotic prescribing based on symptom duration alone or patient pressure—antibiotics have no role in common cold treatment 1, 2, 6
• Prolonged decongestant use leading to rebound congestion—strictly limit to 3-5 days maximum 3, 2
• Missing the 24-hour window for zinc supplementation effectiveness 1, 2
• Unrealistic patient expectations—educate that cold symptoms lasting up to 2 weeks is normal 2