Today’s topic is inspired by the famous complaint of “flu-like symptoms.” More specifically, I’m covering the management of the common cold so you can effectively counsel your patients during discharge.
Setting expectations is crucial when treating patients with viral infections. Symptoms typically peak around days 2-4 of infection but can persist for up to two weeks. Unfortunately, there’s no magic cure; instead, the focus is on managing symptoms as the body fights off the virus. There are many over-the-counter medications available to alleviate these viral symptoms. Though admittedly the “cold and flu” isle is very colorful and rather intimidating, so let’s discuss some of the medications here.
Analgesics, particularly acetaminophen and NSAIDs, are the backbone of managing common cold symptoms. They effectively alleviate headaches, muscle aches, sore throat pain, and fevers. For specifically targeting throat pain, phenol oral anesthetic spray (Chloraseptic spray) or benzocaine-containing lozenges (Cepacol) are effective options.
Antihistamines are designed to treat allergic symptoms like itching, watery eyes, sneezing, coughing, and congestion. First-generation antihistamines, such as diphenhydramine (Benadryl), dimenhydrinate (Dramamine), doxylamine (NyQuil), brompheniramine (Dimetapp), and chlorpheniramine (Chlor-Trimeton) can cause sedation. Second-generation antihistamines, like cetirizine (Zyrtec), fexofenadine (Allegra), and loratadine (Claritin), don’t have this side effect. Antihistamines are commonly used by patients suffering from a cold; however, the data suggests that routine use of these medications doesn’t reduce the duration or severity of cold symptoms.
Cough suppressants work by blocking the nerve impulses that trigger the coughing reflex. Dextromethorphan (Robitussin or Delsym) is a commonly used over-the-counter anti-tussive, while Benzonatate (Tessalon Pearles) acts similarly but requires a prescription. Studies suggest that both medications have some therapeutic effects, but their use should be balanced with their potential side effects. Dextromethorphan is a weak NMDA antagonist (similar to Ketamine) and is often abused for its hallucinogenic and dissociative properties. Benzonatate has a narrow therapeutic index, and overdose can lead to dysrhythmias and seizures, particularly in children.
Decongestants work by constricting nasal blood vessels to reduce swelling and decrease mucus production. Oxymetazoline spray (Afrin) is the most effective decongestant, but it’s important to advise patients not to use it for more than three days to prevent rebound congestion (aka rhinitis medicamentosa). Pseudoephedrine (Sudafed) is a decongestant pill that acts similarly and provides mild relief but it requires an ID to obtain due to its potential as an ingredient in meth. It’s important to distinguish pseudoephedrine (Sudafed) from phenylephrine (Sudafed PE). Phenylephrine is another common decongestant pill that is ineffective and the FDA has recommended it be removed. Vapoinhalers, which contain menthol and/or levmetamfetamine, are becoming increasingly popular as well. These inhalers cause local vasoconstriction in the nose when inhaled, which theoretically provides relief from nasal congestion, but the evidence supporting their effectiveness is limited.
Expectorants help thin and loosen mucus in the airways, making it easier to cough up phlegm. Guaifenesin (Mucinex) is a popular expectorant with questionable efficacy, performing only slightly better than a placebo in clinical studies. Instead, patients can try saline nasal sprays, simple oral hydration, humidifiers, or steam showers which can all moisten the airway to aid in mucus clearance.
Homeopathic or herbal products, such as Oscillococcinum, Zicam, Echinacea, and Pelargonium sidoides, are touted as more “natural” remedies. These products contain botanical or animal derivatives but have no valid evidence supporting their use. (And while we’re on the topic, I’m sorry to say that vitamin C supplements also do not prevent or treat a cold. Unless you’re severely deficient in vitamin C and developing scurvy, most of that Airborne supplement is being peed out.)
Before we end I want to touch on two special topics…
Children are a unique consideration. The American Academy of Pediatrics recommends against giving any over-the-counter cough and cold medicines to children under the age of 6. Instead, they suggest acetaminophen, ibuprofen, and non-pharmacologic options such as nasal suctioning, saline nasal sprays, humidifiers, and steam showers. For children over one year old, honey may soothe the throat and calm a cough.
Combination medications, such as DayQuil, NyQuil, Theraflu, Tylenol Cold + Flu, and more, are found in most pharmacies’ cold and flu sections. These medications typically contain a combination of the aforementioned drugs. As per my best friend, who works in a retail pharmacy, these medications are kinda terrible and should generally be avoided. They are advertised well and commonly perceived as a “cure all” so people end up taking medications they don’t actually need. Instead, she recommends buying individual medications based on your specific symptoms.
And if you’re overwhelmed by what to grab at the pharmacy…
TLDR: Best OTC Cold and Flu Medications
Cough -> dextromethorphan (Delsym)
Congestion -> oxymetazoline spray (Afrin) or pseudoephedrine (Sudafed)
Sore throat -> phenol spray (Chloraseptic) or benzocaine lozenges (Cepacol)
Headache, myalgias, and/or fevers -> acetaminophen and ibuprofen
Sleep -> 3mg melatonin and diphenhydramine (Benadryl)
Sources:
https://pmc.ncbi.nlm.nih.gov/articles/PMC9468790/#CD009345-sec-0103
https://pubmed.ncbi.nlm.nih.gov/36688284/
https://www.ncbi.nlm.nih.gov/books/NBK279544/
