What is the recommended treatment for an otherwise healthy adult with a common cold?

Treatment of the Common Cold

Primary Recommendation

For an otherwise healthy adult with a 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 Antibiotics should never be prescribed, as they provide no benefit and cause more harm than good. 2

Symptomatic Treatment Algorithm

First-Line: Combination Products

• Combination antihistamine-decongestant-analgesic products provide superior relief compared to single agents (odds ratio of treatment failure 0.47; number needed to treat 5.6). 1
• Effective combinations include first-generation antihistamines (brompheniramine) plus sustained-release pseudoephedrine, which reduce congestion and rhinorrhea. 1
• These products address multiple symptoms simultaneously: nasal congestion, rhinorrhea, headache, malaise, and sneezing. 1

Targeted Single-Symptom Treatments

For nasal congestion:

• Oral decongestants (pseudoephedrine or phenylephrine) provide modest benefit. 1
• Topical nasal decongestants (oxymetazoline) are effective but strictly limit use to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa). 2, 1

For rhinorrhea (runny nose):

• Ipratropium bromide nasal spray effectively reduces rhinorrhea but does not improve nasal congestion. 1

For pain, headache, and malaise:

• NSAIDs (ibuprofen 400-800 mg every 6-8 hours) are effective for headache, ear pain, muscle/joint pain, malaise, and also improve sneezing. 1
• Acetaminophen may help nasal obstruction and rhinorrhea but does not improve other symptoms. 1

For cough:

• Dextromethorphan (60 mg for maximum effect) suppresses acute cough, though standard over-the-counter doses are likely subtherapeutic. 1
• Honey and lemon is recommended as a simple, inexpensive home remedy with patient-reported benefit. 1

Evidence-Based Adjunctive Therapies

Zinc lozenges (≥75 mg/day):

• Significantly reduce cold duration BUT only if started within 24 hours of symptom onset. 2, 1
• Use zinc acetate or zinc gluconate formulations. 2
• Critical timing: No benefit if symptoms already established beyond 24 hours. 1
• Potential side effects include bad taste and nausea. 2

Nasal saline irrigation:

• Provides modest symptom relief by diluting secretions and facilitating elimination. 1

Vitamin C:

• May provide individual benefit given its consistent effect on duration and severity, low cost, and safety profile. 2

What Does NOT Work (Avoid These)

Antibiotics:

• No benefit for uncomplicated common cold and contribute to antimicrobial resistance. 2, 1
• Number needed to harm from adverse effects is 8, while number needed to treat is 18. 2

Intranasal corticosteroids:

• Ineffective for acute cold symptoms. 1

Non-sedating antihistamines:

• Newer generation antihistamines (loratadine, cetirizine, fexofenadine) are ineffective. 1

Echinacea:

• Has not been shown to provide benefits for treating colds. 2

Steam/heated humidified air:

• Current evidence does not show any benefits or harms. 2

Expected Clinical Course and When to Reassess

Normal duration:

• Cold symptoms typically last 7-10 days. 1
• Up to 25% of patients may have symptoms for 14 days—this is normal and does not indicate bacterial infection. 1

When symptoms persist beyond 10 days:

• Approximately 25% of patients continue with cough and nasal discharge up to 14 days—this is normal and does not indicate bacterial infection. 1
• Symptoms persisting >10 days without improvement classify as post-viral rhinosinusitis. 1
• Consider intranasal corticosteroids for post-viral symptoms. 1
• Only 0.5-2% of viral upper respiratory infections develop bacterial complications. 1

Red flags requiring reassessment:

• Fever >38°C (100.4°F) persisting beyond 3 days or appearing after initial improvement. 1
• "Double sickening" pattern (initial improvement followed by worsening). 2, 1
• Severe unilateral facial pain suggesting bacterial sinusitis. 1
• Symptoms persisting >10 days with severe symptoms (high fever >39°C and purulent nasal discharge or facial pain lasting at least 3 consecutive days). 2

Common Pitfalls to Avoid

Do not diagnose bacterial sinusitis in the first 10 days:

• 87% of patients show sinus abnormalities on CT during viral colds that resolve without antibiotics. 1

Avoid prolonged decongestant use:

• Topical nasal decongestants must be limited to 3-5 days to prevent rebound congestion. 1

Do not miss the zinc window:

• Zinc supplementation is only effective if started within 24 hours of symptom onset. 1

Manage patient expectations:

• Patients should be advised that symptoms can last up to 2 weeks and should follow up if symptoms worsen or exceed expected recovery time. 2
• Reassure patients that antibiotics are not needed and may have adverse effects. 2