What are the recommended treatments for cold symptoms?

Treatment of Cold Symptoms

For adults with the common cold, use combination antihistamine-decongestant-analgesic products as first-line therapy, which provide significant symptom relief in approximately 1 in 4 patients. 1

First-Line Symptomatic Treatment

Combination products containing a first-generation antihistamine (such as brompheniramine), a decongestant (such as pseudoephedrine), and an analgesic (acetaminophen or NSAID) are strongly recommended for adults with multiple cold symptoms. 2, 1 The American College of Chest Physicians (ACCP) guidelines specifically recommend first-generation antihistamine/decongestant combinations or naproxen as first-line therapy unless contraindications exist (glaucoma, benign prostatic hypertrophy, uncontrolled hypertension, renal failure, gastrointestinal bleeding, or heart failure). 2

Targeted Single-Symptom Management

When patients have isolated symptoms, single-agent therapy is appropriate:

For Nasal Congestion

• Oral decongestants (pseudoephedrine) or topical nasal decongestants (oxymetazoline) provide modest relief but must be limited to short-term use (maximum 3 days) to prevent rebound congestion. 2, 1

For Runny Nose (Rhinorrhea)

• Ipratropium bromide nasal spray is highly effective for reducing rhinorrhea, though it does not improve nasal congestion and may cause minor nasal dryness. 1, 3

For Pain, Headache, and Malaise

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

For Cough

• Central cough suppressants (codeine, dextromethorphan) have limited efficacy for URI-related cough and are not recommended. 2, 5 The ACCP guidelines give these a grade D recommendation (no benefit) for cough due to upper respiratory infections. 2

Evidence-Based Adjunctive Therapies

Zinc Supplementation

Zinc acetate or gluconate lozenges at doses ≥75 mg/day started within 24 hours of symptom onset significantly reduce cold duration. 2, 1 This timing is critical—zinc is ineffective if started after the 24-hour window. 6 Potential side effects include bad taste and nausea. 1

Nasal Saline Irrigation

Saline nasal irrigation provides modest symptom relief without significant adverse effects or drug interactions. 1, 3

Vitamin C

Vitamin C may be worth trying on an individual basis given its consistent effect on duration and severity, low cost, and safety profile. 2, 1

Treatments to Avoid

Antibiotics

Antibiotics have no role in treating the common cold, provide no symptom relief, and contribute to antimicrobial resistance with significant adverse effects. 2, 1, 3 The ACCP guidelines explicitly state antibiotics are not indicated for acute cough from the common cold. 2

Ineffective Medications

• Newer non-sedating antihistamines (loratadine, cetirizine, fexofenadine) are ineffective for cold symptoms. 2
• Intranasal corticosteroids provide no symptomatic relief for the common cold. 2, 1
• Echinacea products do not provide significant benefits. 2, 1
• Over-the-counter combination cold medications are not recommended unless they contain older antihistamine-decongestant ingredients. 2

Clinical Course and When to Reassess

Cold symptoms typically last 7-10 days, with approximately 25% of patients having symptoms for up to 14 days, which is normal and does not indicate bacterial infection. 1, 6 Only 0.5-2% of viral upper respiratory infections develop bacterial complications. 6

Reassess if:

• Symptoms worsen after initial improvement ("double sickening") 6
• Symptoms persist beyond 10 days without any improvement 6
• High fever (>38°C/100.4°F) develops, especially after day 3 6
• Severe unilateral facial pain occurs 6

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on symptom duration alone or patient pressure—prolonged symptoms up to 14 days are normal for viral colds. 1, 6
• Limit decongestant use to short-term only (maximum 3 days)—prolonged use causes rebound congestion. 2, 1
• Do not miss the 24-hour window for zinc effectiveness—it must be started within 24 hours of symptom onset. 1, 6
• Avoid first-generation antihistamine/decongestant combinations in patients with glaucoma, benign prostatic hypertrophy, uncontrolled hypertension, renal failure, gastrointestinal bleeding, or heart failure. 2