The Medical Minute: Getting over over-the-counter confusion

October 16, 2003

By John Messmer, M.D.
Penn State Milton S. Hershey Medical Center

When you have a cold or sinus pressure you may want to treat it. Take a walk in the medication aisle in the pharmacy and you won't have any trouble finding options. You will see something for sinus, something for cough and congestion, one for nighttime, another for days. Another product claims to be a multi-symptom treatment and another is a non-drowsy, multi-symptom sugar free medicine. All of the products come with a list of warnings, but if they are sold over-the-counter, shouldn't they be safe? With all those choices, how do you decide?

If you read the ingredients listed in all the cough and cold products, you will see that there are only a few components common to every over-the-counter (OTC) product -- the doses and combinations vary, but otherwise they are surprisingly similar. Realize first that when you "treat" a cough or cold with OTC medications, you are not treating the disease, just trying to minimize the symptoms. You cannot prevent a cold from becoming more severe with OTC medications -- they are just to help you feel better.

Most colds cause congestion of the nose, ears and sinuses. It becomes difficult to breathe through the nose and the sinus pressure can make your cheeks, eyes and even your teeth hurt. Nasal secretions cause noses to run at an increased level and sometimes cause a recurring cough as the drainage moves into your throat. A decongestant can help to reduce the swelling of the nasal passages and the sinuses while drying the secretions. Nothing will effectively unclog ears.

The only OTC oral decongestant is pseudoephedrine. You may know it as Sudafed. It comes in liquids and pills including sustained release products. Most people tolerate pseudoephedrine without side effects, but some are more sensitive and will experience heart racing, jitteriness or reduced appetite although that is not common. It rarely affects blood pressure and typically the effect is small and tolerable by all but those with very severe high blood pressure or heart disease. It's a good idea to check with your doctor before using it if you have high blood pressure. Most adults need 60 mg every six hours or 120 mg of sustained release every 12 hours to get any benefit. Many find the side effects of the sustained release form to be better tolerated.

Nasal decongestant sprays are very effective at opening clogged noses, but after three or four days, they have a tendency to cause rebound congestion. This can lead to a cycle of increasing use and eventual addiction so limit use to fewer than five days.

Several antihistamines are used in OTC products: diphenhydramine, triprolidine, chlorpheniramine, and brompheniramine are among the more commonly used in cough and cold preparations. Clemastine and loratidine are former prescription antihistamines used primarily for allergies. The antihistamines used in cold preparations tend to dry the membranes. People who have allergies may find them useful, while others may find the mucus becomes too thick to manage well causing increased discomfort. Because many are sedating, they can help a person sleep, but chronic use as a sleeping aid is discouraged due to disruption of normal sleep patterns.

The most effective cough suppressants are narcotics which are available only by prescription. The only OTC cough suppressant is dextromethorphan, a narcotic-like product, which is reasonably effective but has some drawbacks. In doses of about 30 mg for adults, it can reduce coughing in some people. It can interact with the selective serotonin reuptake inhibitor (SSRI) class of antidepressants and one in seven people do not metabolize it properly and can experience hallucinations. If you are not sure you will tolerate it, start with a much lower dose first.

Guaifenesin is an agent that makes secretions thinner so they can be cleared and is available in liquid and pills. It works best if one drinks much water, but drinking lots of water also helps even without the guaifenesin. It can upset the stomach and some people find the taste offensive.

Acetaminophen, more commonly known as Tylenol, relieves pain and reduces fever and is found in many cold and flu products. To be helpful, one must take enough -- at least 650 mg and up to 1000 mg per dose every six hours for most adults. More than 4000 mg daily will not work any better and can be toxic. People who drink several drinks daily should avoid acetaminophen unless recommended by their doctors as it can lead to liver damage.

Ibuprofen, also known as Advil or Motrin, also relieves pain and fever plus it treats inflammation unlike acetaminophen. Most people in general good health can tolerate 400-600 mg of ibuprofen every six hours. The elderly or very ill are more susceptible to stomach irritation and ulcers from this medication and blood pressure can be affected. Many people already take an anti-inflammatory by prescription; if so, they should not also take ibuprofen or the risk of adverse effects is increased. Naproxen (Aleve) is similar but the dose is usually one or two tablets (220-440 mg) every eight hours.

Aspirin is one of the oldest pain relievers and it also reduces fever and inflammation. It has all the potential side effects of ibuprofen and naproxen but more so. Typically, it is avoided in children because of the risk of the potentially fatal Reye's syndrome if taken for chickenpox or influenza.

As many people are aware, alcohol is found in many liquids cold preparations. It helps keep the drugs in solution and has a sedating effect.

You might be tempted to just use a multi-symptom reliever to avoid having to decide which product to use or so you just have to buy one thing. The problem is that you may take medications for symptoms you do not have and may not have a sufficient dose for the symptoms you do have without taking too much of one of the other ingredients.

Since congestion is a common symptom, plain pseudoephedrine in sustained release form is a good first choice for relief. Remember to follow the dosing instructions as symptoms will return when it wears off if you do not repeat the dose.

If pain is not relieved by decongestion, add either ibuprofen or acetaminophen in full doses provided you have no medical reason to avoid them. Avoid aspirin unless your doctor approves it although people who take one aspirin daily to reduce their risk of heart attack may continue to do so even if they are taking ibuprofen or acetaminophen for pain relief.

If you continue to cough despite a decongestant, add dextromethorphan if you tolerate it. It probably will not stop your cough, but it may lessen it. As each symptom resolves you can discontinue the associated medication.

Most people do not need an antihistamine or guaifenesin and one tends to counteract the other anyway. If symptoms continue to increase or last more than two weeks, it's time to visit the doctor.

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Last Updated March 20, 2009