Chicken Soup for the COUGH & COLD: What OTC Product Should I use?
Marisa Boos, Pharm D Candidate 2009.
University of Florida: College of Pharmacy

It’s that time of the year again: the flu season. Approximately 1 billion persons per year will be sick; subsequently, the flu is no walk in the park and most try to treat the accompanying bothersome symptoms: nasal congestion, runny noses, cough, fever and last be not least, the body aches and pains.  Along with wanting to choose the best product to relieve symptoms, one must also consider cost.  There exists a multitude of other-the-counter combination product. The wide variety of products and variances in prices make what should be an easy decision, overwhelming and frustrating. Most OTC cough and cold products contain the same and/or similar active ingredients. Understanding the purpose of each ingredient helps to choose a product that will manage specific symptoms. To help minimize costs, one should purchase a product which targets his/her most bothersome symptom; if two products are being purchased avoid products with the same ingredients. Often times combination products are unnecessary and costly. The following is a brief review of the purpose of the ingredients used in cough and cold medications and what is available.

WHAT DO I NEED?
First, understand which drug class (i.e decongestants versus anti-histamines) treat what symptom and then the differences within that class (i.e phenylephrine versus pseudoephedrine, both examples of decongestants). Keep in mind most drug classes treat more than one symptom, explaining why two products with the same ingredients may be labeled to help with two different conditions.

Decongestants
Pseudoephedrine is only available as tablet (oral) form and not as a nasal spray. Phenylepherine is available as both and the rest are nasal spray only. Generally speaking, pseudoephedrine is preferable over phenylepherine when taken orally; pseudoephedrine is better absorbed into the body and also last longer than phenylepherine.

Nasal decongestants work faster compared to oral, however they cannot be used past 3-5days: patients’ run the risk of developing rebound congestion as the body gets used to the nasal decongestants. Oral decongestants last longer, can be used for a longer duration of time but take slightly longer to see an effect. Nasal decongestants also require the ability of the user to breath in air through his/her nose sufficiently enough to distribute the medication within the nose. Of the OTC nasal decongestants available, oxymetazoline is longer acting.

Anti-Histamines
1st generation anti-histamines are used in cough and cold products predominately for its sedative effects and benefits on reducing coughing and sneezing- which 2nd generation anti-histamines do not possess. Most 2nd generation have very low “anti-cholinergic effect” a property which allows anti-histamines to help with coughing and sneezing. The sedative properties of anti-histamines are due to its ability to cross over into the brain. 2nd generation do not penetrate into the brain as well as 1st generation, thereby they cause less sedation, if any at all.  Most 2nd generations are used in allergy products. One important consideration is the ability of anti-histamines to help with runny noses.  Anti-histamines are of minimal use in OTC cough and cold products – despite the plethora of products which they are in. Anti-histamines help with runny noses that are brought on as a result of HISTAMINE RELEASE – as in the incidence of allergies. With respect to the flu, a runny nose is predominantly caused by the VIRUS and NOT histamine release. The antihistamines do block mucus fluid produced in the nose – however this fluid production is beneficial in the case of a common cold; the nasal secretions acts as part of the body’s mechanisms to clear the virus via the nasal mucus. The same concept holds true for antihistamines ability to manage sneezing due to a cold.

Antitussive
Dextromethrophan is the only OTC cough product available which helps to suppress. 1st generation anti-histamines, specifically diphenhydramine, also act as antitussives, however they are not considered first line. Products with DM in the name typically contain dextromethrophan.

Expectorants (Protussives)
Guaifenesin relieves coughs with mucus production. The combination of an expectorant and amble amounts of water will help to clear lungs of mucus.

Sore Throat
Lozenges typically contain one of two products, or combine both to sooth an irritated throat. The first one is an anesthetic (i.e benzocaine) which numbs the throat. The other is an antibacterial (i.e phenol) to protect against infection.  Lozenges provide short term relief. Another simple remedy is to gargle with luke warm salt water.

Fever/Aches/Pains
In general all antipyretics and analgesics will help provide relief from these symptoms. Examples include aspirin, acetaminophen and ibuprofen. One product may be preferred based on patients medical history (i.e history of liver failure, hypertension) or prior experience. Typically aspirin is not recommended to children for fevers due to risk of Reye’s Syndrom. To treat children with fever consider using acetaminophen.

WHAT OTC COUGH & COLD PRODUCTS ARE AVAILABLE?

Despite the vast number of combination cold and cough products, there are only so many combinations of the basic cough and cold medicines one can have, before everything is the same and redundant. At this point, the market for cough and cold combination products have taken the same  basic ingredients and manipulated prices by varying the combinations and paying for a product with a specific name – not necessarily indicating the product will manage the symptoms any better than store/generic brand.  One should read the label carefully and only select the product with the medicine which helps with the specific symptom and not additional symptoms which he/she is not experiencing. (i.e if nasal congestion is the concern choose a product with a decongestant alone – avoid products which treat cough and fever). Remember a cold is a virus – it cannot be treated; however the symptoms are manageable with OTC. The best cost effective measures for a cold are to do just like individuals did 100 years ago, when OTC products were not available: eat properly, drink lots of fluids and rest, rest, rest!

Comparison of Antihistamines. Pharmacist’s Letter/Prescriber’s Letter 2008;24(7):240707.
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Green, Alan “Over-the-Counter drugs for cold,flu, allergy, and sinus Infection.”  ADAM. April 4,2007. http://adam.about.com/care/allergy/allergy_otcdrugs.html.   November 13,2008.
Berardi, Rosemary et al. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 15th Ed.  American Pharmacists Association 2006. “Disorders related to Cold and Allergy.” Pages:202-213.
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