Another cold and flu season is upon us, with an added layer of confusion due to COVID-19. With so many products to choose from, it is easy for patients to get overwhelmed. Here is a breakdown of what you can find in these products, and counselling tips to keep in mind.
Used to treat: headaches, sinus pain, muscle aches, fever, sore throat
Drugs: acetaminophen, ibuprofen, acetylsalicylic acid
Many of the combination products on the market contain an analgesic, which isn’t always needed. If a patient isn’t experiencing pain or fever, they don’t need one of these products. For patients who choose an NSAID product (e.g., Advil Cold & Sinus), remind them that it’s important to avoid doubling up with other NSAIDs. Acetylsalicylic acid products should not be used in anyone under 18 with cold or flu symptoms due to the risk of Reye’s syndrome.
Used to treat: nasal congestion
Drugs: pseudophedrine, phenylephrine, xylometazoline, oxymetazoline
Decongestants can be found in combination oral products, as well as topical products like nasal sprays. Rebound congestion after 3-5 days of use is common with topical products. Systemic decongestants (pseudoephedrine and phenylephrine) should not be used in children under 6, and used with caution in patients with hypertension, heart disease or diabetes.
Used to treat: rhinorrhea, cough, allergic rhinitis
Drugs: diphenhydramine, chlorpheniramine, doxylamine succinate
First-generation antihistamines have significant anticholinergic effects. While this may help treat postnasal drip (which in turn causes cough), they have an extensive side effect profile. First-generation antihistamines can be found in many “PM” or “night time” cough, cold, and flu products. These agents should not be used in children under 6.
Used to treat: cough
Drugs: dextromethorphan hydrobromide, codeine
There is a lack of evidence for efficacy of OTC antitussive agents in treating cough due to upper respiratory tract infections. Additionally, both DM and codeine have documented abuse potential. Most guidelines do not recommend either agent be used in children.
Used to treat: mucus buildup
While guaifenesin is generally well-tolerated with few side effects, a 2014 Cochrane review found very little evidence for its efficacy. It should not be used in children under 6. Of note, there are a variety of combination products on the market that contain both an expectorant, and an antitussive agent. As these agents theoretically have opposing mechanisms of action, taking them simultaneously is unlikely to have any benefit.
Used to treat: sore throat
Drugs: benzocaine, menthol
Benzocaine lozenges and sprays may offer temporary relief for sore throat, but should not be used in young children due to the risk of methemoglobinemia, a condition that involves a decrease in oxygen delivery to the tissues.
So, the next time you're in the cold and flu aisle, take a look at the ingredients in some of the best sellers at your store. Remember to check the label carefully before recommending a product to someone, as a lot of common ingredients have important contraindications.
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Allan GM, Arroll B. Prevention and treatment of the common cold: making sense of the evidence. CMAJ 2014;186:190-9.
Prchal, JT. Methemoglobinemia. In: Post T, ed. UpToDate. Waltham, MA.: UpToDate; 2020. www.uptodate.com. Accessed November 17, 2020.
Smith S, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in community settings. Cochrane Database Syst Rev. 2014 Nov 24;2014(11):CD001831
Thirion DJG. Viral Rhinitis, Influenza, Rhinosinusitis and Pharyngitis. In: Compendium of Therapeutics for Minor Ailments. Ottawa, ON: Canadian Pharmacists Association. Updated May 1, 2018. Accessed November 14, 2020.