American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, February 18, 2011

Treating the common cold

For the last week I have had a cold. I usually get one each winter. I have two kids in school and they bring home a lot of viruses. I also work in a hospital, which tends (for some reason) to have lots of sick people. Although this year I think I caught my cold while traveling. I'm almost over it now, but it's certainly a miserable interlude to my normal routine.

No273 13 Oct 2009 Sneeze by mcfarlandmo via FlickrOne thing we can say for certain about the common cold, it's common. It is therefore no surprise that there are lots of cold remedies, folk remedies, pharmaceuticals, and "alternative" treatments. Finding a "cure for the common cold" has also become a journalistic cliche. Reporters will jump on any chance to claim that some new research may one day lead to a cure for the common cold. Just about any research into viruses, no matter how basic or preliminary, seems to get tagged with this headline. (It's right up there with every fossil being a "missing link.")

But despite the commonality of the cold, the overall success of modern medicine, and the many attempts to treat or prevent the cold, there are very few treatments that are actually of any benefit. The only certain treatment is tincture of time. Most colds will get better on their own in about a week. This also creates the impression that any treatment works. No matter what you do, your symptoms are likely to improve. It is also very common to get a mild cold that lasts just a day or so. Many people my feel a cold "coming on" but then it never manifests. This is likely because there was already some partial immunity, so the infection was wiped out quickly by the immune system. But this can also create the impression that whatever treatment was taken at the onset of symptoms worked really well, and even prevented the cold altogether.

What works
There is a short list of treatments that do seem to have some benefit. Nonsteroidal anti-inflammatory drugs (NSAIDs), like aspirin, ibuprofen and naproxen, can reduce many of the symptoms of a cold: sore throat, inflamed mucosa, aches and fever. Acetaminophen may help with the pain and fever, but it is not anti-inflammatory and so will not work as well. NSAIDs basically take the edge off, and may make it easier to sleep.

Decongestants may also be of mild benefit. Antihistamines have a mild benefit in adults, but not documented in children. There are also concerns about safety and side effect in children. Overall, other than some TLC and NSAIDS (although not aspirin) parents should probably not give their children anything for a cough or cold. The benefit of antihistamines in adults is very mild and of questionable value. There is better evidence for antihistamines in combination with a decongestant, but the benefits are still mild. Nasal sprays are probably better than oral medication, and overall use a much lower dose. These treatments do not seem to have any effect on the course of the cold, but may relieve symptoms. Perhaps the best use of nasal spray decongestants is just prior to going to sleep, to reduce a post nasal-drip cough that can be very disruptive to sleep.

There is weak evidence for the use of hot liquids. There does not seem to be any advantage to chicken soup over other hot liquids, like tea. They may provide a symptomatic benefit in clearing the sinuses and loosening phlegm so that it can be cleared easier. Since this is a low-risk intervention (just make sure the liquids are not too hot for small children), if it makes you feel better, go for it. There also may not be any advantage over just humidified air to help keep the membranes moist. Honey may be soothing, but there is no evidence of real benefit.

A neti pot looks like a small teapot with a thin spout that is meant to pour hot liquids up your nose to irrigate your sinuses. The evidence for the use of neti pots is mixed. Briefly, there is no evidence for their routine or preventive use, and in fact they may be counterproductive. However, they may be useful for acute symptoms of sinus congestion. The concept is actually simple and well established--irrigating an infected space to help wash out the germs and prevent impaction. There is probably no benefit to using a neti pot for a regular cold unless you have significant sinusitis and feel that your sinuses are clogged. And again, this is probably no better than just moist air or hot liquids.

What doesn't work
In short, everything else.

Over-the-counter (OTC) cough suppressants simply do not work and are not safe in children. If you have a serious cough, the kind that can cause injury, you need prescription medication (basically narcotics, like codeine). Also, in most cases using a cough suppressant makes no sense, especially in combination with an expectorant. You want to cough up the mucus and phlegm. If your cough is caused by a sore throat, take an NSAID. If it's post nasal drip, treat the congestion as above. And if it's severe, see your doctor. But don't bother with OTC cough suppressants.

I have covered echinacea previously in detail. It does not work for the prevention or treatment of the cold or flu.

Vitamin C has been a favorite since Linus Pauling promoted in decades ago. But decades of research has not been kind to this claim. The research has failed to find a consistent and convincing effect for vitamin C in treating or preventing the common cold. For routine prevention, the evidence is dead negative. For treating an acute infection, there is mixed evidence for a possible very mild benefit, but this is likely just noise in the research.

What about homeopathic treatments? Since homeopathy is one big pseudoscientific scam, its products are nothing but water, and they don't work for anything, I don't need to go into more detail here.

Finally, there is some evidence that zinc or zinc oxide may reduce symptoms of a cold, but this evidence is mixed and unconvincing at present. At best the benefit is very mild (again, likely within the noise of such studies). Further, zinc comes with a nasty taste (something that also complicates blinding of studies) and many people may find this worse than symptoms it treats. Zinc oxide nasal sprays have been linked to anosmia (loss of smell, which can be permanent) and is certainly not worth the risk to treat a self-limited condition like the cold, even if they did work, which is unclear.

The common cold remains a difficult syndrome to treat effectively. In most cases it is best to just let the cold run its course. Limited use of NSAIDs and decongestants may be helpful. Otherwise, if there is an intervention that is risk free and makes you feel better, do it.

We all need to feel comforted when we're sick. But don't waste your time or money on other medications, supplements, herbs, or other concoctions. There are also endless snake-oil products out there, too many to deal with here. A good default position is simply not to believe any product that claims to prevent or treat the common cold. And don't be compelled by the anecdotal evidence of your neighbor's cousin's boss. Everyone thinks they have the secret to treating the cold, but no one does. It's all placebo effect and confirmation bias.

This post by Steve Novella, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Blogger Camera Repair said...

I'd have to side with the people who suggest that regular use of their neti pot may help to actually PREVENT the flu. See . I started using neti about five years ago B.O. (Before Oprah) to help with allergy relief. That it does very well. But noted a possible side benefit in that I haven't come down with a single case of cold or flu in that five years. Coincidence? I don't know, but I can tell you that I regularly came down with a sickness every year prior to starting use of the neti. Really do think there may be something to it.

February 19, 2011 at 11:06 AM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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