My Favorite Things at the Pharmacy: Cold & Flu Edition
5 Medicine Cabinet Essentials 🤧
ICYMI 👉
I went to CVS this weekend to get my flu shot. While waiting my turn for the jab, I took a spin through the technicolor dream-like world of cold and cough remedies on display. I tried to put myself in my patients’ shoes: Do I need Nyquil or Dayquil? Mucinex DM, Mucinex D, or plain old Mucinex? Is generic Robitussin okay, or do I splurge on the brand name?
Recall that approximately 90% to 95% of upper respiratory infections (URIs) are caused by viruses—and only about 5% to 10% are due to bacterial infections. Of course, bacterial infections can occur, especially as secondary infections following a viral URI. However, the fall and winter season is marked by a parade of viral infections. The common culprits? Rhinovirus, adenovirus, influenza virus (the “flu”), parainfluenza virus, respiratory syncytial virus (RSV), human metapneumovirus, the seasonal coronaviruses, the novel coronaviruses (aka COVID), and more.
Distinguishing between viral and bacterial infections is important because antibiotics are ineffective against viruses. Testing can help. For example, my office offers a nasal PCR test that detects the genetic material of 22 different viruses and bacteria. This is particularly helpful for people whose specific diagnosis will change treatment or behaviors (for example, a positive COVID test might trigger a Paxlovid prescription, or a positive RSV test might mean skipping a visit to see a newborn baby). However, testing isn’t always needed when treatment for most viruses is symptom management.
I tend to steer clear of multi-symptom cold remedies—that is, syrups and pills that have more than one active ingredient, many of which have side effects. I prefer to target specific symptoms instead. Generic versions are fine!
So, in honor of cold and flu season, here are my 5 favorite things at the pharmacy for cold and flu season:
Nasal saline
Fun fact: new data shows that good old saline nasal spray can reduce the severity and duration of respiratory symptoms from colds and flus. This is great news because nasal saline is cheap and harmless. Rinsing your nose and sinuses with saline is an easy way to mobilize mucus and debris. Unlike decongestants such as pseudoephedrine (Sudafed) which can elevate blood pressure and heart rate or certain antihistamines such as diphenhydramine (Benadryl) which can be sedating, nasal saline is a winner for anyone with a stuffy nose.
Guaifenesin
This is a gem of a product. The common brand names are Mucinex or Robitussin. Guaifenesin is an expectorant. It works by thinning mucus in the airways. When mucus is less thick and sticky, it is less irritating to the airways and easier to clear it out by coughing.
Be sure to read labels carefully: Robitussin as a brand makes formulations that include dextromethorphan (a cough suppressant) and/or phenylephrine (a decongestant). Mucinex as a brand also offers multi-symptom formulations, such as Mucinex DM, which contains dextromethorphan for cough suppression, and Mucinex D, which adds pseudoephedrine as a decongestant.
I tend to avoid decongestants because they can cause jitteriness, high blood pressure, a rapid heart rate, insomnia and other stimulating effects. I also tend to avoid cough suppressants in patients who are sick with lots of mucus. Why? Coughing is a necessary protective reflex that helps keep the airways clear. When mucus accumulates in the respiratory tract, it can obstruct airflow and serve as a breeding ground for other bacteria or viruses. In other words, coughing helps with breathing and helps reduce the risk of secondary infections.
Of course in some cases, suppressing a cough makes sense—for example, a dry, unproductive cough that is causing discomfort or difficulty sleeping. Suppressing juicy coughs can be okay, too, if the benefits (such as getting a good sleep!) outweigh the downsides. But in general it’s better to thin mucus than it is to suppress a cough when you’re sick.
Steroid nasal sprays
Nasal steroids such as fluticasone propionate (Flonase) or triamcinolone acetonide (Nasacort) are real workhorses. Formerly by prescription only, these nasal sprays can help turn the proverbial sprinkler system off in the nasal passages and sinuses. Basically they reduce inflammation on mucosal surfaces. You might already take one of these sprays for seasonal allergies (and indeed they are an appropriate tool in the toolbox for allergies to things like pollen, dust and mold), however they can also provide relief for nasal congestion associated with colds and flus.
The nasal steroids are generally very safe, however one downside is that they can thin and dry out the mucus membranes enough to cause nose bleeds. If that happens, you can apply Vaseline to add moisture and cut back on using the spray (and of course see your doctor for specific advice).
Antihistamines
Antihistamines are old faithfuls. Over the counter fexofenadine (Allegra), loratadine (Claritin), cetirizine (Zyrtec), or levocetirizine (Xyzal) are commonly recommended for allergy symptoms but can help alleviate symptoms of colds and flu, too. They work by blocking the action of histamine, a substance in the body that contributes to allergic reactions and inflammatory responses that cause sneezing, runny nose, and excess mucus production. In drying up the production of mucus and swelling in the nasal passages, they also reduce post-nasal drip and cough.
The potential downsides are 1) antihistamines are drying, and when nasal and sinus passages are dry they sometimes ache, and 2) certain antihistamines such as diphenhydramine (Benadryl) and cetirizine (Zyrtec) can be sedating, so I remind people to take these two in particular at bedtime.
Ibuprofen
Ibuprofen is my personal favorite. Also known as Advil or Motrin, this power player can help alleviate certain colds and flu symptoms by reducing fever, body aches, and pain from a sore throat or headaches. As a nonsteroidal anti-inflammatory drug (NSAID), Ibuprofen helps reduce inflammation in the body, which may provide relief from nasal congestion and discomfort.
However, especially if taken in excess, there are downsides of Ibuprofen, some of which can be serious. It can cause gastroesophageal reflux, gastritis, stomach ulcers, abdominal pain, kidney dysfunction, and liver dysfunction, to name a few. So for people with a sensitive stomach or known kidney disease, caution is key. Even for those with iron stomachs and normal kidney function should take Ibuprofen with plenty of water and not take more than the recommended dose without consulting their physician.
The upshot
None of these medications is essential, nor are they cures for colds and flus. Most people do fine with hydration, rest, and time. However, it’s nice to have a kit in your back pocket to alleviate symptoms as needed.
Of course, getting vaccinated against COVID, flu and RSV if appropriate is key, especially for those at high risk!
What are your questions and comments? I’m all ears!
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Disclaimer: The views expressed here are entirely my own. They do not reflect those of my employer, nor are they a substitute for advice from your personal physician.
You are like the Statue of Liberty: a beacon for all of us.
Sooo many thanks.
Super helpful, thanks Dr. Lucy! It's always confusing trying to figure out the best product to buy/use when you're feeling crummy, and this clarifies things a lot.