Strategies for managing the common cold

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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.

  1. 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.
  2. 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.
  3. 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.

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.

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.

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.

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A couple of comments.

First, humidifiers. If you keep the humidity in the spaces you live in around 45%, your respiratory system will be in a better position to fight the cold off. No, I have no peer reviewed studies on this, but someone really should do a study.

Second, sleep. A couple of the things you are using, including the oxymetazoline, probably are keeping you up. Certainly you can fight that with benadryl (and I've used that trick), but another simpler trick is to drink less caffeine. You're taking stims anyway -- if you are moderately addicted and stay away from coffee after the early morning, you'll probably sleep pretty easily.

Also, you did not mention guaifenesin. It is an excellent over the counter expectorant, and especially if you're developing bronchitis and coughing a lot, it can be of tremendous help. There is a superdose of it available over the counter called "mucinex" -- if you're having trouble with coughing from serious congestion, it works really well. One caution, though, it has pretty dramatic effects in terms of what you'll hack up.

A word about echinacea. We now have double blind studies on it. It does not work.

One last comment -- especially if you are in too dry an environment, a viral respiratory infection can develop secondary "opportunistic" bacterial infections. If you haven't been taking care of yourself and you start developing green or yellow, er, discharge, you might have developed a bacterial infection. That doesn't necessarily mean you need to go on antibiotics immediately, but it does mean that you bloody well have to start taking care of yourself and stop ignoring the illness. You can easily develop pneumonia from a bacterial respiratory infection, and that will make you very unhappy indeed.

Sufferers in more enlightened jurisdictions will of course want to purchase Tylenol-1 with codeine at their friendly neighbourhood drugstore, substituting it for ibuprofen in the foregoing formula for maximum cough suppression.

(And, yes, I'm afraid echinacea is rapidly meeting the fate of all therapeutic fads.)

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