Prescription for Severe Cold and Cough in 49-Year-Old Patient
For a 49-year-old with severe cold and cough, prescribe a first-generation antihistamine-decongestant combination (brompheniramine 12 mg + pseudoephedrine 120 mg sustained-release, twice daily) plus naproxen 220-440 mg twice daily for symptomatic relief. 1, 2
Primary Prescription
Rx: Brompheniramine/Pseudoephedrine SR
- Brompheniramine 12 mg + Pseudoephedrine 120 mg (sustained-release)
- Sig: Take 1 tablet by mouth twice daily
- Disp: #14 tablets
- Refills: 0
- Duration: 7 days 1, 2
Rx: Naproxen
- Naproxen 220 mg tablets
- Sig: Take 1-2 tablets by mouth twice daily with food
- Disp: #28 tablets
- Refills: 0
- Duration: 7 days 1
Rationale for This Combination
Why First-Generation Antihistamine-Decongestant
The ACCP guidelines specifically recommend first-generation antihistamine-decongestant combinations as Grade A evidence for acute cough associated with the common cold. 1 This is based on controlled trials showing substantial benefit, with approximately 70% of patients reporting favorable response versus 55% with placebo. 2
The mechanism of action is primarily through anticholinergic properties rather than antihistamine effects, which explains why newer non-sedating antihistamines are completely ineffective for cold symptoms. 2, 3 The anticholinergic effect reduces secretions and limits inflammatory mediators. 2
Alternative combinations include dexbrompheniramine 6 mg + pseudoephedrine 120 mg twice daily, or azatadine 1 mg + pseudoephedrine 120 mg twice daily. 2 All have demonstrated efficacy in randomized controlled trials. 1
Why Add Naproxen
Naproxen provides additional cough suppression beyond the antihistamine-decongestant combination. 1 The ACCP guidelines specifically state that naproxen can be administered to help decrease cough in the setting of common cold. 1
NSAIDs like naproxen are effective for associated symptoms including headache, ear pain, muscle/joint pain, and may improve sneezing. 3, 4
Critical Contraindications to Screen For
Before prescribing, verify the patient does NOT have:
- Symptomatic benign prostatic hypertrophy or urinary retention (antihistamines contraindicated) 2, 5
- Narrow-angle glaucoma (antihistamines contraindicated) 2, 5
- Uncontrolled hypertension or heart disease (decongestants may worsen) 5, 6
- Recent or planned coronary artery bypass graft surgery (NSAIDs absolutely contraindicated) 6
- History of peptic ulcer disease or GI bleeding (NSAIDs increase risk) 6
- Severe renal or hepatic impairment (NSAIDs may worsen) 6
Dosing Strategy to Minimize Side Effects
Start with bedtime dosing only for 2-3 days before advancing to twice-daily dosing to allow tolerance to sedation. 2 This minimizes daytime drowsiness while still providing symptom relief.
Warn the patient about potential sedation, dry mouth, and urinary hesitancy from the antihistamine component. 2, 3 Advise against driving or operating machinery until they know how the medication affects them. 2
Take naproxen with food to minimize GI upset. 6 Avoid alcohol and other NSAIDs while taking naproxen. 6
What NOT to Prescribe
Do NOT prescribe:
Antibiotics - The ACP/CDC guidelines explicitly state antibiotics should not be prescribed for common cold, as they provide no benefit and lead to significantly increased risk for adverse effects. 1 Bacterial sinusitis should not be diagnosed during the first week of symptoms. 1
Second-generation antihistamines (loratadine, fexofenadine, cetirizine) - These are completely ineffective for cold symptoms and should not be used. 1, 3 The ACCP gives these a Grade D recommendation (no benefit). 1
Codeine or other opioid antitussives - Codeine is no more effective than placebo for cough due to upper respiratory infection. 1, 7 The ACCP guidelines state central cough suppressants have limited efficacy for URI-related cough and are not recommended (Grade D). 1
Over-the-counter combination products unless they contain first-generation antihistamine-decongestant ingredients specifically. 5 Most OTC products contain ineffective ingredients. 1
Expected Timeline and Follow-Up
Improvement typically occurs within days to 2 weeks of starting treatment. 2 Patients should be advised that cold symptoms can last up to 2 weeks. 1
Instruct the patient to follow up if:
- Symptoms worsen or persist beyond 10 days (consider bacterial sinusitis) 1
- High fever >39°C with purulent nasal discharge or facial pain for ≥3 consecutive days 1
- "Double sickening" pattern (initial improvement followed by worsening after 5 days) 1
- Development of hemoptysis, progressive breathlessness, or voice changes 5
Approximately 25% of patients will have persistent cough, post-nasal drip, or throat clearing at day 14, which may represent post-infectious upper airway cough syndrome requiring continued treatment. 1
Alternative Options if First-Line Fails
If no improvement after 7-10 days on first-generation antihistamine-decongestant:
Consider adding ipratropium bromide nasal spray (0.06% solution, 2 sprays per nostril 3-4 times daily) for persistent rhinorrhea. 1, 5, 7 This is the only inhaled anticholinergic recommended for URI-related symptoms. 1
Add dextromethorphan 10-15 mg three to four times daily (maximum 120 mg/day) if cough remains bothersome despite other measures. 5, 7 This is the preferred antitussive with superior safety profile compared to codeine. 5
Consider intranasal corticosteroids if symptoms suggest developing rhinosinusitis, though these are more effective for allergic rhinitis than viral URI. 1
Adjunctive Non-Pharmacologic Measures
Recommend saline nasal irrigation for nasal congestion and rhinorrhea - this has benefits with minimal side effects. 1, 3
Adequate hydration and humidified air may provide symptomatic relief without adverse effects. 7
Honey (1-2 teaspoons as needed) can be used as a simple demulcent for cough relief. 5, 4
Hand hygiene is the most effective method to reduce spread, as transmission occurs primarily through direct hand contact. 1, 4
Special Considerations for Age 49
At age 49, this patient is at intermediate risk for NSAID-related adverse effects. 6 The risk increases with longer use, so limit naproxen to 7 days maximum. 6
Monitor for signs of fluid retention, elevated blood pressure, or GI symptoms while on naproxen. 6
The sedating effects of first-generation antihistamines may be more pronounced than in younger patients, reinforcing the importance of starting with bedtime dosing. 2, 5