How to Navigate OTC Cold and Flu Drugs

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A pharmacist and a doctor weigh in on the best options

by
Rachael Robertson, Enterprise & Investigative Writer, MedPage Today
October 30, 2024

The cold and flu aisles of pharmacies are bursting with options, though most share a relatively small roster of active ingredients in various combinations. MedPage Today spoke with a pharmacist and a physician to find out which over-the-counter (OTC) drugs are actually effective — and which ones patients should leave on the shelves.

Jack Kann, RPh, MPA, MBA, director of pharmacy at South Shore University Hospital in Bay Shore, New York, told MedPage Today that the best approach to cold and flu medicine is matching the specific symptoms with the right active ingredient.

A lot of common OTC drugs have multi-symptom formulas, which Kann said can lead to taking unnecessary medicine with potentially unnecessary side effects.

Pieter Cohen, MD, of Cambridge Health Alliance in Massachusetts who has long studied OTC supplement products, agreed that multi-symptom drugs aren’t the best approach.

“I recommend avoiding the ones with combination ingredients, because when you have combination ingredients, it’s much harder to understand what you’re treating,” Cohen told MedPage Today. Having numerous active ingredients makes it “really hard to figure out what effect it’s going to have,” he said.

Instead, he recommends a single-ingredient approach targeting specific symptoms. Cohen said that acetaminophen (Tylenol) — which can reduce fever and pain — and antihistamines, like loratadine (Claritin) or diphenhydramine (Benadryl) — which can alleviate symptoms like sneezing and runny nose — are the workhorses of cold and flu, and tend to be a good starting point.

Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil) or acetylsalicylic acid (Aspirin) work well for treating pain and fever, too, though they come with more side effects than acetaminophen, he said. Kann added that different antihistamines work better for different people, so there’s a level of trial and error in finding a good match.

When it comes to other types of OTC cold and flu medicine — like expectorants, cough suppressants, and decongestants — Cohen said the evidence to support efficacy is weaker.

Last year, an FDA advisory committee determined that oral phenylephrine — the only OTC decongestant, found in popular products like Sudafed PE and Suphedrine PE — doesn’t work.

“There’s not a lot of great decongestants,” Kann added, also noting that pseudoephedrine, which moved “behind-the-counter” nearly two decades ago, is much more effective than phenylephrine.

“I would not try to take anything by mouth to try to decongest your nose,” Cohen said.

He noted that nasal sprays containing corticosteroids like fluticasone can be helpful, though they can take a week or so to work. On the other hand, Cohen recommends against using nasal sprays containing oxymetazoline (Afrin). Oxymetazoline works as a quick decongestant and while it’s not dangerous, it can be dependency forming.

“I frequently see patients who have become dependent to breathe on oxymetazoline nasal spray from over the counter, so they have to carry it with them at all times and if they stop using it, their nose just completely blocks up,” he said. “This is because there’s a phenomenon of a rebound problem, where the nasal passages get bigger in response to overuse of this and if someone doesn’t stop, it can eventually cause permanent damage to the nose.”

Thus, he strongly advises patients not to take oxymetazoline even for one day.

Cohen said for nasal decongestants, expectorants, and cough suppressants, he’d generally skip OTC and opt for a prescription if he really needed something to alleviate specific symptoms. During the interview, Cohen had a lingering cough from a recent cold — and he said he had taken nothing for any of his symptoms.