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Four Rules for Choosing Cough and Cold Products 

It is that time of year again, when the common cold—a virus—becomes more common.  Hopefully, you wash your hands frequently, cough into your elbow, and drink plenty of fluids to help prevent getting sick.  However, for most people, catching a cold will be unavoidable this winter.  Many people seek nonprescription drug therapy to reduce the bothersome symptoms of stuffy nose, scratchy throat, runny nose, watery eyes, and cough.  Older adults often take other medicines or have underlying medical conditions and thus must be extra careful in choosing the right cough and cold products.  Drug interactions and adverse drug effects must be everyone’s first concern.  This blog will summarize the good and bad about the different nonprescription cough and cold products and provide tips for how to choose a safe and effective product.

RULE #1:  Buy only the ingredients that you need; focus on single-ingredient products.     

Drug companies do a great job of marketing every type of product to soothe symptoms.  Nonprescription products often combine multiple ingredients, use slick packaging, and make promising statements to lure consumers.  Use of unneeded ingredients only leads to greater risk of interactions with drugs or medical conditions, side effects, and higher cost. 

RULE #2:  Very few cough and cold products are truly effective.  

There are 5 basic ingredients that are found in the various cough and cold products.  Each is explained below, along with a comment on how effective they are.   Safety issues are discussed separately.  

1. Antihistamines are used to dry up excessive secretions.  This means they help with symptoms like runny nose, watery eyes, and sneezing. First-generation antihistamines have important side effects (see below), especially in older adults.  Thus, if you are 65 years or older, you should avoid using these antihistamines.  Specific names are listed in the table.  Newer antihistamines (such as loratadine) have fewer side effects, but do not have a role in treating cough and cold symptoms.  There are very little data to support that benefits (effectiveness) of antihistamines are greater than risks (side effects), especially in older adults.
2. Decongestants are used to reduce nasal stuffiness.  They are available as oral products (tablets, capsules, liquid) or nasal sprays.  The oral decongestants are pseudoephedrine and phenylephrine.  Pseudoephedrine is more effective than phenylephrine, but it is found only behind the pharmacy counter.  For treating a stuffy nose, nasal sprays are recommended.  They have few side effects and interactions.  Nasal sprays should not be used for more than 3 to 5 days because they cause worsened congestion (called rebound congestion).  
3. Expectorants loosen secretions and make it easier to cough up phlegm.  Drinking lots of water can help loosen secretions, too, but many patients cannot or do not drink enough water.  Thus, expectorants can be helpful for some patients.   
4. Cough suppressants (antitussives) should be used selectively.  The main role for using a cough suppressant is when a cough is severe enough to prevent the ability to speak or get a good night’s sleep, or if the cough is dry and nonproductive.  Experts recommended that you do not suppress a productive cough, because coughing up phlegm is a good thing.  
5. Pain relievers—The common cold typically does not cause achiness.  Nonetheless, many combination products include a pain reliever.  There are 3 types to be aware of: acetaminophen, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs).  All are effective, however, side effects and interactions differ with each and can be serious, especially in older adults (more on this below).  For most older adults, acetaminophen often is the safest choice, but check with your pharmacist first, of course.

Table:  Generic names of ingredients in nonprescription cough and cold products

RULE #3:  Cough and cold products are not safe for everyone.  Check with your pharmacist.

            Nonprescription products are medicines.  As such, they can cause adverse events like side effects and drug interactions.  Older adults are more susceptible to these types of problems, many of which can be avoided by choosing the proper products.  Every patient is unique.  With so many nonprescription products from which to choose and the potential combinations with different medical conditions and prescribed medications, taking the time to check with the community pharmacist can be a life saver.

RULE #4:  Your pharmacist is your best defense to prevent medication-related problems.

Below is a summary of the most common safety issues with cough and cold products, focusing on patients who are 65 years and older.  Not all safety issues are included here.  Importantly, only general comments about interactions are included; specific drugs or medical conditions are not named.  Patients should always check with their pharmacist.

Antihistamines – Side effects include sedation or drowsiness and confusion; also dry eyes, dry mouth, constipation and difficulty urinating.  These drugs can impair alertness and cognitive function and should be avoided by older adults.  Antihistamines can have important interactions both with other drugs and with certain medical conditions.

Oral decongestants – Side effects include increased heart rate and blood pressure, nervousness, dizziness, and difficulty sleeping.  Oral decongestants should be used with caution in patients with high blood pressure, diabetes, enlarged prostate, and heart disease. Some drug interactions are possible, as well.  Nasal decongestants have few safety issues.  They can cause local irritation.  If used longer than 3 to 5 days, they can worsen congestion, as mentioned above.

Expectorants and cough suppressants – Guaifenesin and dextromethorphan rarely cause side effects.  Dextromethorphanhas important drug interactions, including several antidepressant medications, for example.

Pain relievers – Aspirin and NSAIDs can cause serious bleeding complications.  NSAIDs also can cause kidney damage and heart attack or stroke.  Too much acetaminophen can lead to liver damage. Acetaminophen is found in many nonprescription and prescription products, so always read ingredients or prescription labels to know if there is acetaminophen in different medicines you take.  Because of the several side effect and interaction concerns with pain relievers, it is best to avoid when possible; see Rule #1.

Summary and Take Home Points

The products marketed to treat symptoms of the common cold in general are of limited benefit.  Side effects, drug-drug interactions, and drug-disease interactions are major concerns when choosing and using these products.  Remember the 4 rules presented above.  Ask your pharmacist for help in choosing the safest ingredients for you.  Finally, prevention is the best approach as cold season is upon us.

Written by Hedva Barenholtz Levy, PharmD, BCPS, BCGP

Last reviewed 12/17/20 

References: 

Hatton RC, Hendeles L. Over-the-counter phenylephrine: a placebo for nasal congestion.  J Allergy Clin Immunol Pract 2015;3:709-10.

Scolaro KL. Disorders related to colds and allergy. In: Handbook of nonprescription drugs, an interactive approach to self-care, 17^th ed. Krinsky DL, Berardi RR, Ferreri SP et al. eds. American Pharmacists Association, Washington DC: 2012.

Tietze KJ. Cough. In: Handbook of nonprescription drugs, an interactive approach to self-care, 17^th ed. Krinsky DL, Berardi RR, Ferreri SP et al. eds. American Pharmacists Association, Washington DC: 2012.

Young SS. Appropriate use of common OTC analgesics and cough and cold medications. CE Monograph. American Academy of Family Physicians. 2008. 

This material is informational only and not intended to replace the guidance of your health care team.