This morning I woke up with a cold. That's the bad news. The
good news (for both me and you) is that I have a highly
evolved strategy for managing it using a complex and finely tuned
array of prescription and nonprescription pharmaceuticals, and I'm
now motivated to write that up. But first a warning:
I've developed this strategy via a combination of reading the
literature and trial and error, which means that (1) it's suited to
the cluster of symptoms that bug me and (2) while I'm generally satisfied,
it's not something I'd be willing to write up in the NEJM.
Basic principles
I want to start with some basic principles which it's important
to keep in mind throughout the discussion.
The first thing you need to do is accept that you're going to be sick for a while. Your
goals for cold management are two-fold: minimize the duration of
the time you're sick and suppress as many of the symptoms as possible.
The good news is that we have drugs that will suppress most of your
symptoms. The bad news is that they have side effects. The result is
that cold management is to a great degree about managing the side
effects of the various meds you're taking to suppress your cold symptoms.
Because of the side effect issue, you generally want to stay away from
all-in-one cold preparations, like NyQuil. These generally consist of a bunch of
common cold drugs shoved into a single pill. They're designed to suppress all the
symptoms everyone has, which means they probably suppress symptoms you
don't have, which means you're getting side effects you don't want.
(The big one here is that a lot of them contain antihistamines,
which make you drowsy).
Accordingly, I generally advise sticking with individual drugs to get
the effects you want. It's more work, but you get finer control.
Managing Congestion
My major cold complaint is nasal congestion. If I just feel general
malaise, I can lie around and watch TV, read, or sleep, but when I'm congested,
I'm constantly miserable and it makes it hard for me to sleep--which
makes it hard to get better. So,
getting uncongested is job number one. I have a three prong strategy
here.
- Flonase is a corticosteroid nasal spray that
is used to treat nose-related allergies (I hear that
Beconase works well too).
If you're taking it on a daily
basis anyway, then you're probably in good shape here, but you might
want to up the dosage to 100 mcg (two sprays)/nostril/day if you're
not on that already. If you're not taking it on a daily basis (I only
need it during allergy season) you want to start on it as soon as you
feel the cold symptoms.
I find that Flonase does a pretty good job of
suppressing congestion (and sneezing and runny nose),
but the problem is that it takes 2-3 days to
take effect, and even then you're probably not 100% clear. That's
where prongs two and three come in.
One note here: Flonase is prescription only, so you may have trouble
getting a prescription for cold management.
- Nasal spray (I use oxymetazoline Hcl) is by far the most effective
decongestant I've ever found. The problem is that if you use
it regularly you can get rebound congestion) when you stop.
I deal with this by only using nasal spray at night and using the minimum
possible dose. I find that one spray per nostril is typically fine and as
I get better and not quite so stuffed up I alternate one nostril every
other night. But if you're only using nasal spray at night, then you're
still congested during the day. This is where pseudoephedrine comes in.
- Pseudoephedrine is an oral decongestant. You can get either an immediate
release form (30 mg tabs) or an extended release (120 mg over 12 hours
or 240 mg over 24 hours). I generally prefer the extended release form
for two reasons. First, I find that I get more consistent relief
throughout the day. Second, pseudoephedrine is a mild stimulant and
I find that the extended release form makes me less jittery. The
stimulant effect also means that pseudoephedrine is not so great to
use at night, so that's where I use the nasal spray.
Cough
After a couple of days of nasal congestion and post-nasal drip, you're
likely to be coughing pretty badly. The state of the art in non-prescription
cough relief is dextromethorphan (the stuff in Robitussin DM)
I recommend Delsym, which is just dextromethorphan
in an extended release package, so you get 12 (well, really about 8) hours
of cough relief, which allows a good nights sleep.
Delsym works pretty well, but the gold standard for cough
relief is opiates. The standard drug seems to be this stuff
called tussionex, which is an antihistamine combined
with hydrocodone (the active ingredient in Vicodin). The truth
of the matter is that it's the opiate that's really doing the job,
and pretty much any opiate will do. If you have some Vicodin
(hydrocodone + acetaminophen) hanging around, that will work
just as well. As an added bonus, the opiate will help you sleep,
which, as I've said, is crucial for getting healthy.
Aside from being hard to get your hands on, the other problem
with the opiates is that they're sedating, so you're not
going to be getting much done. Stick with Delsym for the day
and save the opiates for nighttime use.
Aching
This is more of a flu symptom, but people do get it with colds
too. One word: ibuprofen. On the other hand, if you're popping
Vicodin to deal with your cough, you probably aren't going
to have much of an aching problem.
Insomnia
Of course, if you feel like crap, especially if you're congested
(see above), you may have trouble falling asleep. I generally
avoid antihistamines for cold treatment. I don't find that they
work that well and they're pretty sedating,
which interferes with getting stuff done. Actually, I suspect
that these problems are related, since I suspect that for
a long time there was a drowsiness/effectiveness tradeoff
(until Seldane and the rest of the non-drowsy antihistamines
came out), so the all-in-one cold med makers had to compromise.
In this case, however, drowsiness is a feature, not a bug, so
there's no need to compromise.
What I recommend here is diphenhydramine (benadryl).
Diphenhydramine is much more sedating than the standard antihistamines
that go into cold meds (typically chlorpheniramine or brompheniramine maleate)--it's actually used as a nonprescription
sleeping aid. 50mg (two tablets) is a pretty good dose.
Another option, of course, is to use a prescription sleeping drug
such as Halcion or Ambien, but my general experience is that
for this application diphenhydramine is a better choice,
probably because it's helping suppress the cold symptoms as well.
The one downside is that it can leave you a bit drowsy in the mornings,
so use sparingly.
Minimizing the duration
So far I've mostly been focusing on symptom suppression, because it's
not clear that you can do much to actually shorten the course of
a cold. The only treatment that's shown any real promise at all
is zinc nasal spray, but there's only one small
study
that shows it works, and there's the whole anosmia issue to consider. I've been
known to use zinc nasal spray, but I can't strongly recommend it.
However, even if there's nothing you can do to shorten the
duration of a cold, you can definitely lengthen it, mainly
by not taking care of yourself, not getting enough sleep, etc.
This is a particular problem if you're doing a good job of
symptom suppression, since you may feel good enough to almost
forget that you're sick.
A note for athletes on training while sick
One question that athletes often want to know is whether they can
train when they're sick. The standard
rule of
thumb is that if the symptoms are above the neck it's safe to
exercise but if it's below the neck you shouldn't. I don't
know of any actual scientific basis for this, however.
What I generally do is follow this rule but cut back to
mostly easy cardio workouts until I feel better. Actually,
I generally find that
you have to take it easy even after you feel better, since your
athletic performance tends to be suppressed even after you've
started to feel better the rest of the day. If you take morning
heart rates, they can be a good indicator of when you're
ready to train again.