What is the initial therapy for an otherwise healthy adult with a typical cold, considering potential comorbidities such as hypertension, asthma, or chronic obstructive pulmonary disease (COPD)?

Initial Therapy for the Common Cold

Do not prescribe antibiotics for the common cold, as they provide no benefit and increase the risk of adverse effects; instead, offer symptomatic therapy with first-generation antihistamine/decongestant combinations or naproxen as first-line treatment in adults without contraindications. 1

Primary Treatment Approach

Antibiotics: Never Indicated

• Antibiotics are explicitly not recommended for the common cold, as they are ineffective against viral infections and significantly increase the risk of adverse effects 1
• The common cold is a self-limited viral illness that resolves without antimicrobial therapy, typically within 2 weeks 1, 2
• Antibiotics do not prevent complications such as acute bacterial sinusitis, asthma exacerbation, or otitis media 1

First-Line Symptomatic Therapy

For adults without contraindications, prescribe first-generation antihistamine/decongestant combinations or naproxen 220-440 mg as initial therapy. 1

• First-generation antihistamine/decongestant combinations provide significant symptom relief in 1 out of 4 patients treated 1
• Naproxen (a nonsteroidal anti-inflammatory drug) is strongly recommended by the American College of Chest Physicians unless contraindicated 1
• Newer-generation nonsedating antihistamines should NOT be used, as they are ineffective for cold symptoms 1

Important Contraindications to Consider

Before prescribing antihistamine/decongestant combinations or NSAIDs, screen for the following contraindications:

• For antihistamine/decongestants: glaucoma, benign prostatic hypertrophy, uncontrolled hypertension 1
• For naproxen/NSAIDs: renal failure, gastrointestinal bleeding history, congestive heart failure 1
• For NSAIDs in patients with asthma: Use with extreme caution, as cross-reactivity with aspirin can cause severe bronchospasm that can be fatal 3

Special Considerations for Comorbidities

Hypertension

• NSAIDs including naproxen can lead to new-onset hypertension or worsening of preexisting hypertension 3
• Blood pressure should be monitored closely if NSAIDs are used 3
• Decongestants (oral or topical) should be used cautiously, as they can elevate blood pressure 4
• Consider avoiding both NSAIDs and decongestants in poorly controlled hypertension; use simple analgesics like acetaminophen instead 5

Asthma or COPD

• Do not use NSAIDs in patients with aspirin-sensitive asthma, as severe bronchospasm can occur 3
• Use NSAIDs with extreme caution even in patients with non-aspirin-sensitive asthma 3
• Inhaled ipratropium bromide can relieve nasal symptoms and may be particularly useful in patients with underlying airway disease 1, 6
• Monitor closely for asthma exacerbation, which is a recognized complication of the common cold 1
• If cough worsens after initial improvement (biphasic course), consider bacterial sinusitis or other complications requiring different management 1

Heart Failure

• Avoid NSAIDs in patients with severe heart failure unless benefits clearly outweigh risks 3
• NSAIDs can cause fluid retention, edema, and worsening heart failure 3
• If NSAIDs must be used, monitor patients closely for signs of worsening heart failure 3

Additional Symptomatic Therapies

Effective Options

• Topical nasal decongestants (e.g., oxymetazoline) or oral decongestants (pseudoephedrine, phenylephrine) for up to 3 days only to relieve nasal congestion in adults 6, 4, 7
• Inhaled ipratropium bromide for rhinorrhea 1, 6
• Zinc supplements (acetate or gluconate) if started within 24 hours of symptom onset, though weigh benefits against adverse effects like nausea and bad taste 1, 7
• Simple analgesics (acetaminophen) for fever and discomfort 5

Ineffective Therapies to Avoid

• Vitamin C and echinacea have no proven benefit for treatment (though vitamin C prophylaxis may have modest effects) 1, 7
• Codeine has not been shown to effectively treat cough caused by the common cold 6
• Over-the-counter combination cold medications lack evidence unless they contain older antihistamine/decongestant ingredients 1

Critical Pitfalls to Avoid

Decongestant Overuse

• Limit topical nasal decongestants to 3 days maximum to prevent rebound congestion 6, 4
• Repeated doses of nasal decongestants over several days show no significant benefit over placebo 4

Duration and Follow-Up

• Advise patients that symptoms can last up to 2 weeks 1
• Instruct patients to follow up if symptoms worsen after initial improvement or exceed 2 weeks, as this may indicate bacterial complications requiring antibiotics 1
• A biphasic course (initial improvement followed by worsening) suggests bacterial sinusitis or pertussis 1

Patient Education

• Emphasize that handwashing is the most effective method to reduce transmission 1
• Reassure patients that antibiotics are not needed and may cause harm 1
• Explain that the common cold affects only the upper respiratory tract in otherwise healthy adults, with no clinically important lower respiratory tract involvement 2