What is the recommended treatment for a patient with a common cold, considering over-the-counter medications and potential underlying medical conditions such as asthma or chronic obstructive pulmonary disease (COPD)?

Treatment of the Common Cold

First-Line Therapy

For adults with the common cold, start with a first-generation antihistamine/decongestant combination (such as brompheniramine with sustained-release pseudoephedrine) as the primary treatment, which provides substantial symptom relief in approximately 1 in 4 patients. 1, 2, 3

Primary Medication Options

• First-generation antihistamine/decongestant combinations are the most effective single intervention, significantly reducing nasal congestion, postnasal drainage, sneezing, throat clearing, and cough 1, 2, 4
• NSAIDs (naproxen, ibuprofen) should be added for headache, malaise, myalgia, sore throat, and fever—naproxen specifically decreases cough associated with the common cold 1, 2, 4
• The combination of ibuprofen/pseudoephedrine is most effective when started within the first 2 days of symptom onset and when using two tablets at first dosing rather than one 5

Medications That Do NOT Work

• Never prescribe antibiotics for the common cold—they provide zero benefit for symptom reduction or illness duration and significantly increase adverse effects and antimicrobial resistance 1, 2, 3, 6
• Newer non-sedating antihistamines (loratadine, cetirizine, fexofenadine) are completely ineffective for common cold symptoms 1, 3, 4, 6
• Intranasal corticosteroids provide no symptomatic relief for the common cold 1, 3
• Central cough suppressants (codeine, dextromethorphan) have limited efficacy for URI-related cough and are not recommended 1, 3, 6
• Zinc preparations are not recommended for acute cough due to the common cold 1
• Over-the-counter combination cold medications lack evidence unless they contain older antihistamine/decongestant ingredients 1, 2

Special Considerations for Patients with Asthma or COPD

Asthma Patients

• Monitor closely for asthma exacerbation, which is a recognized complication of the common cold 2
• Do not use albuterol for acute or chronic cough not due to asthma—it is ineffective 1
• The standard first-generation antihistamine/decongestant combination remains appropriate unless contraindicated 1, 2

COPD Patients

• Inhaled ipratropium bromide is the only inhaled anticholinergic recommended for cough suppression in patients with URI or chronic bronchitis—it provides substantial benefit 1, 2
• Ipratropium nasal spray is highly effective for reducing rhinorrhea, though it does not improve nasal congestion 3, 6
• Continue standard COPD maintenance therapy (regular β2 agonist and anticholinergic combinations) as prescribed 1
• Do not use albuterol specifically for the cold-related cough unless the patient has underlying asthma or COPD requiring it 1

Additional Evidence-Based Therapies

Moderately Effective Options

• Zinc lozenges (acetate or gluconate at ≥75 mg/day) significantly reduce cold duration if started within 24 hours of symptom onset, though benefits must be weighed against adverse effects like nausea and bad taste 1, 2, 3, 6
• Nasal saline irrigation provides modest symptom relief without drug interactions or significant adverse effects 3
• Vitamin C may provide individual benefit given its consistent effect on duration and severity, low cost, and safety—worth trying on an individual basis 1, 3

Ineffective Therapies to Avoid

• Echinacea products have not been shown to provide benefits 1, 3
• Acetaminophen may help nasal obstruction and rhinorrhea but does not improve sore throat, malaise, sneezing, or cough 7, 8

Expected Clinical Course and Red Flags

Normal Duration

• Cold symptoms typically last 7-10 days, with approximately 25% of patients having symptoms for up to 14 days—this is normal and does not indicate bacterial infection 1, 2, 3
• On day 14, approximately 25% of untreated patients continue to have symptoms of cough, postnasal drainage, and throat clearing 1

When to Reassess for Complications

• Biphasic course (initial improvement followed by worsening) suggests bacterial sinusitis or pertussis and requires different management 2, 4
• Symptoms persisting more than 10 days without any improvement classify as post-viral rhinosinusitis 3
• Do not diagnose bacterial sinusitis during the first week of symptoms—87% of patients with recent-onset colds have sinus abnormalities on CT scan that resolve without antibiotics 1
• Only 0.5-2% of viral upper respiratory infections develop bacterial complications 3
• Reassess if high fever develops, focal chest signs appear, dyspnea or hypoxemia occurs, or symptoms worsen after initial improvement 2, 4

Critical Pitfalls to Avoid

• Do not prescribe antibiotics based on symptom duration alone or patient/family pressure—purulent (green or yellow) sputum does not signify bacterial infection 1, 3
• Limit topical decongestants to short-term use only to prevent rhinitis medicamentosa (rebound congestion) 1, 3
• Use decongestants cautiously in patients with hypertension (may elevate blood pressure) or diabetes (pseudoephedrine may elevate blood glucose) 4
• Emphasize handwashing as the most effective method to reduce transmission 2
• Advise patients that symptoms can last up to 2 weeks and instruct them to follow up only if symptoms worsen after initial improvement or exceed 2 weeks 2, 3