What over‑the‑counter medications and dosing are appropriate for symptomatic relief of a common cold with cough in an otherwise healthy adult, and what are the contraindications and pediatric dosing recommendations?

Cold and Cough Medicine for Adults

For an otherwise healthy adult with common cold and cough, use a first-generation antihistamine combined with a decongestant—specifically brompheniramine 12 mg plus sustained-release pseudoephedrine 120 mg twice daily—as this is the most effective evidence-based treatment. 1, 2

First-Line Treatment: Antihistamine-Decongestant Combinations

Recommended Regimens for Adults

• Brompheniramine 12 mg + pseudoephedrine 120 mg (sustained-release) taken twice daily is the preferred combination based on randomized controlled trials. 1, 2

• Alternative combinations with equivalent efficacy include:

  • Dexbrompheniramine 6 mg + pseudoephedrine 120 mg (sustained-release) twice daily 1, 2
  • Azatadine 1 mg + pseudoephedrine 120 mg (sustained-release) twice daily 2

• These combinations provide symptom relief in approximately 25% of treated adults, with improvement typically occurring within a few days to 2 weeks. 1, 2

Why This Works (and Why Newer Antihistamines Don't)

• First-generation antihistamines work primarily through anticholinergic properties, not antihistamine effects—they reduce nasal secretions and suppress inflammatory mediators that trigger cough. 1, 2

• Second-generation antihistamines (loratadine, cetirizine, fexofenadine) are completely ineffective for cold symptoms because they lack anticholinergic activity and should never be used. 1, 2

Dosing Strategy to Minimize Sedation

• Start with bedtime dosing only for the first few days, then advance to twice-daily dosing to reduce daytime sedation (occurs in 13-14% of patients). 2

• The sedative effect can actually be beneficial for nocturnal cough by helping with sleep. 1, 2

Absolute Contraindications to Decongestant-Containing Products

Screen for these conditions before prescribing pseudoephedrine: 2

• Narrow-angle glaucoma
• Symptomatic benign prostatic hypertrophy or urinary retention
• Severe uncontrolled hypertension
• Congestive heart failure
• Renal failure

Monitor blood pressure after starting pseudoephedrine, as it can cause hypertension, tachycardia, and palpitations. 2

Cough Suppressants

Dextromethorphan

• Dextromethorphan 60 mg is the preferred antitussive due to superior safety compared to opioids, with maximum cough suppression at this dose. 1

• It has demonstrated efficacy in suppressing acute cough in meta-analyses. 1

• Avoid codeine—it has no greater efficacy than dextromethorphan but carries a much worse adverse effect profile. 1

• Standard over-the-counter dextromethorphan doses (15-30 mg) may be suboptimal; higher doses up to 60 mg are more effective. 1

Adjunctive Symptomatic Treatments

NSAIDs

• Naproxen or ibuprofen improve cough and relieve associated headache, ear pain, and muscle aches. 2, 3

Non-Pharmacological Options

• Honey and lemon mixtures are recommended as first-line treatment and are often as effective as pharmacological treatments. 1

• High-volume nasal saline irrigation (≥150 mL) mechanically clears mucus and reduces nasal edema, offering greater benefit than simple saline spray. 2, 3

Ipratropium Nasal Spray

• Ipratropium bromide is highly effective for reducing rhinorrhea in adults. 2

Treatments to Avoid

• Antibiotics have no role in viral upper respiratory infections and should not be prescribed during the first week of symptoms, even with purulent nasal discharge. 1, 2

• Intranasal corticosteroids provide no benefit for the common cold. 4

• Guaifenesin (expectorant) shows mixed benefit in trials and is not strongly recommended. 5, 6

Pediatric Dosing Recommendations

Children 6-12 Years

• Brompheniramine 12 mg + pseudoephedrine 120 mg (sustained-release) twice daily (same adult formulation). 2

• Diphenhydramine 25 mg every 4-6 hours, maximum 6 doses per 24 hours. 2

• Dextromethorphan: Follow age-appropriate dosing on FDA-approved products. 7

• Pseudoephedrine 30 mg (1 tablet) every 4-6 hours, maximum 4 tablets in 24 hours. 8

Children 2-6 Years

• Guaifenesin 2.5-5 mL (½ to 1 teaspoonful) every 4 hours, maximum 6 doses per 24 hours. 5

• Antihistamine-decongestant combinations should be used with extreme caution in this age group.

Children Under 2 Years

• Do not use over-the-counter cough and cold medications—there is no evidence of benefit and potential for harm. 3

• Consult a physician for any medication use in this age group. 5

Children Under 6 Years

• Pseudoephedrine is contraindicated in children under 6 years. 8

• There is no evidence of benefit for antihistamine-decongestant combinations in children under 6 years, and they should be avoided. 2

Common Pitfalls

• Do not diagnose bacterial sinusitis during the first week of illness, even with purulent nasal discharge—this is indistinguishable from viral rhinosinusitis. 2

• Approximately 25% of patients with common cold-related cough have persistent symptoms at day 14 that respond to antihistamine-decongestant therapy, not antibiotics. 2

• If cough persists beyond 2 weeks despite adequate antihistamine-decongestant therapy, consider alternative diagnoses: upper airway cough syndrome, asthma, or gastroesophageal reflux disease. 1, 2

• Nasal decongestant sprays (oxymetazoline) should be used for only 3-5 days maximum to avoid rebound congestion. 4