This blog is being devoted to one question- “What is the most effective way to treat the nasal symptoms of a cold”? I am addressing this as a result of a recent medical journal article. For most people with the “common cold”, it is the runny, congested, sneezing nose that causes us the most discomfort, so this seems appropriate.
However, before this can be addressed, two questions need to be answered: 1. What is evidence-based medicine, and 2. What is the Cochrane Library of systematic reviews? In a nutshell, evidence-based medicine utilizes the results from well-designed and well-analyzed studies, along with clinical expertise to guide the treatment of a patient. A specific question is formulated, and the results of numerous studies are typically evaluated by a panel of experts and clinicians and then aggregated to answer it. As part of the conclusion, the strength of the information is evaluated, very often ranging from low quality to high quality evidence or degrees of risk versus benefit. This approach (which I have highly simplified) is then applied to determining the best intervention or treatment for a patient or a condition. Very often, these numerous queries are grouped into databases. One well-known database is the Cochrane Libraries. Their researches have looked at thousands of clinical questions and then scoured the literature for the best evidence-based answers.
That being said, this past October, the British Medical Journal, a prestigious and well-reviewed source of information, published an article (BMJ 2018;363:k3786) entitled, What treatments are effective for common cold in adults and children? (I would recommend that everyone look up the article, as they have a great graphic that explains everything I am about to summarize.) The authors searched the Cochrane libraries, other databases and specific articles that were not found in these collections and from this investigation, classified most of the known interventions for nasal symptoms into four areas: 1. Small or possible beneficial effect 2. No or unclear effect 3. Likely to be harmful 4. No evidence of effect. In doing so, they addressed the 3 most common nasal symptoms- congestion, runny nose and sneezing when evaluating treatments.
In the first category, “Small or possible beneficial effect”, they concluded that the combination of an analgesic plus decongestant spray possibly had an effect on the severity of congestion (low quality of evidence), but no effect on runny nose or sneezing, and there was an increased risk of side effects (moderate quality evidence) from a decongestant; such as nervousness, insomnia, palpitations, etc. The combination of an antihistamine, decongestant spray and analgesic possibly had a benefit on congestion, runny nose (low quality of evidence) but no effect on sneezing and may place one at risk for adverse events such as sedation, insomnia, palpitations, etc. A pure decongestant spray, alone, had a small effect on congestion (low quality of evidence), but none on runny nose or sneezing and if used properly no increased risk of an adverse event. Anti-inflammatories (ibuprofen, naproxen, etc.) had only a small effect of the severity of sneezing, but none on any of the other symptoms. Antihistamines, alone, had no effect on severity of congestion, a small effect on severity of a runny nose and a small effect on sneezing, but for all 3 symptoms the effect on how long the symptoms lasted of them was unclear; in other words, do they shorten their duration?
The next category was “No or unclear effect”. An antihistamine plus an analgesic showed there was an unclear effect on reducing the severity of congestion or sneezing and no data regarding effects upon a runny nose. Using just an analgesic alone such as acetaminophen had no effects on any of the 3 nasal symptoms. Using a non-sedating antihistamine alone had an unclear effect on the severity of nasal congestion and no effects on a runny nose or sneezing. African geranium extract also known as Pelargonium sidoides (becoming popular) had an unclear effect on congestion and there was no data or studies that looked at its effects on a runny nose or sneezing. Salt water nose irrigation yielded the same conclusions- possibly no effect on congestion, and no data regarding its effects on sneezing or running of the nose.
Under “Likely to be harmful”, were antibiotics. As we have told our patients on numerous occasions, antibiotics do nothing for the common cold. In some situations, they may be used to prevent a complication in someone so prone; however, this should be discussed with your healthcare provider.
Under the last category, “No evidence of effect” on nasal symptoms of congestion, runny nose and sneezing were: antivirals, Chinese medicinal herbs, Echinacea, Eucalyptus oil, increased fluid intake, garlic, ginseng, heated humidified air, honey, probiotics, vapor rubs, Vitamin C and zinc. With almost all of these substance there was no data to support their efficacy on reducing any of the nasal symptoms associated with the common cold.
So, what can we conclude from this exhaustive review? The first is that they were looking at nasal symptoms, and not necessarily cough, body aches or sore throat. It is always a fine line as to whether to treat a symptom and cause an adverse effect or “grin and bear it. Coughing is a sign of irritation to the respiratory tract, and nature’s way of clearing it of debris or invaders. An irritative, dry cough is a significant nuisance that not only can keep you awake, but further spread your virus to those around you. If you are going to use something for coughing, it is always best to use a single substance medication rather than a combination of ingredients some of which you most likely don’t need. In this case, over the counter dextromethorphan would be a good choice. But, be aware of a potential interaction between certain antidepressants and this medication. Ask your healthcare provider or pharmacist first.
Most non-Streptococcal (non-Strept) sore throats can be treated with salt water gargles, lozenges and agents that soothe and prevent dryness. Unless the Streptococcal test or culture is positive, there is little role for antibiotics in treating this symptom.
A fever is the body’s response to an infection and may play a role in stimulating immune cell functions and delaying viral reproduction. A low-grade fever with a cold may not need treatment. Significant body aches or headaches might. It is beyond the scope of this blog to discuss when or why a fever may need to be treated; speak to your healthcare provider
So, in summary, “What works best for nasal symptoms?” Whatever does the least harm, is used for the shortest amount of time, and is understood by you that it may do little. Please be aware that nasal decongestant sprays, if used for more than 3 days or more frequently than the directions indicate, can lead to significant rebound congestion and problems. As far as dealing with a cold, in general, the tried and true advice still pertains: get rest, drink plenty of fluids, and take measures to prevent spreading it to others (wash your hands, cover your mouth when coughing or sneezing, and stay home). But foremost of all, when in doubt as to what to do, call your healthcare provider!