What is the recommended treatment for a patient with coryza (common cold)?

Treatment of Coryza (Common Cold)

The common cold requires only symptomatic management with combination antihistamine-decongestant-analgesic products providing the most effective relief—antibiotics are never indicated as this is a self-limiting viral illness. 1, 2

Immediate Assessment: Rule Out Complications

Before initiating symptomatic treatment, identify red flags that suggest bacterial complications or alternative diagnoses:

• Fever >39°C (102.2°F) with purulent nasal discharge or facial pain lasting ≥3 consecutive days suggests bacterial sinusitis requiring antibiotics 1
• "Double sickening" pattern (initial improvement followed by worsening after day 5) indicates possible bacterial superinfection 1, 2
• Symptoms persisting >10 days without any improvement warrant consideration of bacterial rhinosinusitis 1
• Hemoptysis requires chest radiograph 3
• Respiratory distress (increased rate, retractions, breathlessness) needs urgent evaluation 3

Critical pitfall: Do not diagnose bacterial sinusitis during the first 10 days of symptoms—87% of patients show sinus abnormalities on CT during viral colds that resolve without antibiotics. 2

First-Line Symptomatic Treatment

Most Effective: Combination Products

Use combination antihistamine-decongestant-analgesic products as first-line therapy, with 1 in 4 patients experiencing significant symptom relief (NNT 5.6, odds ratio of treatment failure 0.47). 2, 3

• Specific effective combination: First-generation antihistamine (brompheniramine) + sustained-release pseudoephedrine + analgesic (ibuprofen or naproxen) 1, 2
• This combination is superior to single agents for reducing congestion, rhinorrhea, and systemic symptoms 2

Important caveat: Newer non-sedating antihistamines (loratadine, cetirizine, fexofenadine) are ineffective for common cold symptoms and should not be used. 1

Individual Symptom Management

For nasal congestion:

• Oral decongestants (pseudoephedrine 60 mg or phenylephrine 10 mg every 4-6 hours) provide modest benefit 2, 3
• Topical nasal decongestants (xylometazoline, oxymetazoline) are highly effective but limit use to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa) 2, 3, 4

For rhinorrhea:

• Ipratropium bromide nasal spray (0.06% solution, 2 sprays per nostril 3-4 times daily) effectively reduces nasal discharge but does not improve congestion 2, 3

For pain, headache, and systemic symptoms:

• NSAIDs (ibuprofen 400-800 mg every 6-8 hours or naproxen 220-440 mg every 8-12 hours) are effective for headache, ear pain, muscle/joint pain, malaise, and also improve sneezing 2, 3
• Acetaminophen may help nasal obstruction and rhinorrhea but does not improve other symptoms 2

For cough:

• Dextromethorphan 60 mg for maximum cough suppression (standard OTC doses of 15-30 mg are likely subtherapeutic) 2, 3
• Honey and lemon is recommended as a simple, inexpensive home remedy with patient-reported benefit 2, 3
• Menthol inhalation provides acute but short-lived cough suppression 2

Critical evidence: Central cough suppressants (codeine, dextromethorphan) have limited efficacy for URI-related cough and are not strongly recommended. 1

Adjunctive Therapies with Evidence

Zinc lozenges (≥75 mg/day total dose) significantly reduce cold duration BUT only if started within 24 hours of symptom onset—no benefit if symptoms already established beyond 24 hours. 1, 2

• Use zinc acetate or zinc gluconate formulations 2
• Potential side effects include bad taste and nausea 1, 2

Nasal saline irrigation provides modest symptom relief by diluting secretions and facilitating elimination. 1, 2

What Does NOT Work (Avoid These)

• Antibiotics have no benefit for uncomplicated common cold, contribute to antimicrobial resistance, and cause more adverse effects than benefits (NNH 8) 1, 2
• Non-sedating antihistamines (loratadine, cetirizine) are ineffective 1
• Intranasal corticosteroids for acute cold symptoms 2
• Zinc preparations if started >24 hours after symptom onset 1
• Albuterol for cough not due to asthma 1

Management of Prolonged Symptoms (>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, 2, 3

If symptoms persist >10 days without improvement:

• Continue symptomatic treatment with combination antihistamine-decongestant products 2, 3
• Consider intranasal corticosteroids for post-viral rhinosinusitis 2, 3
• Only suspect bacterial infection if ≥3 of these criteria are present: purulent nasal discharge, severe local pain, fever >38°C, "double sickening" pattern, elevated inflammatory markers 2

Key point: Only 0.5-2% of viral URIs develop bacterial complications. 2

Patient Education

• Cold symptoms typically last 7-10 days, with up to 25% lasting 14 days 1, 2, 3
• The illness is self-limiting and viral—antibiotics will not help and may cause harm 1, 2
• Sore throat peaks early and resolves by day 3-4, while nasal congestion and cough persist longer 2
• Maintain adequate fluid intake 3
• Hand hygiene is the best prevention method 3

Special Populations

Pregnant women: Acetaminophen is first-line for pain and fever. 2

Neutropenic or immunocompromised patients: Respiratory virus testing (including influenza, parainfluenza, adenovirus, RSV, human metapneumovirus) and chest radiography are indicated for patients with upper respiratory symptoms including coryza. 1