Worst Pills, Best Pills

An expert, independent second opinion on more than 1,800 prescription drugs, over-the-counter medications, and supplements


November 10, 2004

Many prescription or over-the-counter drug combinations of two or more ingredients should not be used because they are irrational combinations of single ingredients, some of which are safe and effective and sensible to use alone if treating the symptom for which they are intended. The combinations, however, present extra risks for extra ingredients that will usually not add any benefit (possibly a risk) to the first ingredient and will invariably cost much more than the single ingredient...

Many prescription or over-the-counter drug combinations of two or more ingredients should not be used because they are irrational combinations of single ingredients, some of which are safe and effective and sensible to use alone if treating the symptom for which they are intended. The combinations, however, present extra risks for extra ingredients that will usually not add any benefit (possibly a risk) to the first ingredient and will invariably cost much more than the single ingredient alone. They represent a “shotgun” approach to multiple symptoms of colds, coughs, and allergies that rarely occur in force in the combination that is suggested by the two ingredients in these products. (See Combination Antihistamines, Decongestants, and/or Cough Preparations for details of these drugs.)

The viral infection we call “the common cold” can usually be treated without any professional help by rest and plenty of liquids, occasionally aided by the use of simple over-the-counter (nonprescription) remedies for relief of certain symptoms. There are no drugs that can kill the viruses that cause colds.

A cold cannot be “cured,” except by time, but you are less likely to catch a cold if you do not smoke, since smoking paralyzes the hairlike cells (cilia) that clean out the body’s airways. Colds are usually spread by hand more often than they are spread through the air. It’s a good idea to prevent the spread of viruses by trying not to touch your eyes, mouth, or nose, and by washing your hands frequently when you are ill or with an ill person.

Certain other illnesses appear similar to colds but warrant medical advice. If you have a high fever (above 101 degrees Farenheit, or 38.3 degrees Centigrade) accompanied by chills and you are coughing up thick phlegm, or if coughing or breathing deeply causes sharp chest pain, you may have pneumonia. You should call your doctor for diagnosis and appropriate treatment.

The safest, best, and least expensive way to care for a cold is to not take anything at all and let the illness run its short, usually self-limiting course. If necessary, purchase single-ingredient products to treat the individual symptoms that you have.

What Is the Common Cold?

The common cold is a viral infection of the upper respiratory tract (nose, throat, and upper airways), resulting in inflammation of the mucous membrane lining of those areas. The most common symptoms are runny nose, sneezing, and a sore throat. The sore throat accompanying a cold is the most common kind of sore throat.

How to Treat a Cold

Nondrug Measures

A cold is best treated without drugs by drinking plenty—at least 8 to 10 full (eight-ounce) glasses per day—of nonalcoholic liquids (especially warm or hot liquids), getting enough rest, and not smoking.

Drugs to Use

If symptoms do not respond to these nondrug measures and interfere with normal activities, the following products are safe and effective. Please note that all of the drug products we recommend for treating various cold symptoms—stuffy nose, fever, nonproductive cough—are available without a prescription (over-the-counter [OTC]). None of the prescription cough or cold drugs is recommended; they are classified as Do Not Use.

For a runny nose: No OTC or prescription drug is appropriate. A runny nose promotes drainage and should not be treated with medication. If it lasts longer than a week, call your doctor.

For a stuffy nose: If your nose is blocked, especially if you can’t breathe through it, use nose drops or spray containing oxymetazoline hydrochloride (AFRIN, for example), xylometazoline hydrochloride (OTRIVIN NASAL SPRAY, for example), or phenylephrine hydrochloride (NEO-SYNEPHRINE nose drops and nasal spray, for example). Buy a less expensive generic or store brand product of any of these if it is available. Do not use these drugs for more than three days because they can cause local irritation and then promote congestion.

For fever, headaches, and body aches: Use aspirin or acetaminophen, if needed. (Also see Reye’s Syndrome Warning in Salicylates and Nonsteroidal Anti-inflammatory Drugs.) For a cough: A productive cough (when you are coughing something up) should not be treated. An unproductive (dry) cough associated with a cold also does not require treatment (see Types of Coughs).

Cold Remedies (Not to Use)

Oral nasal decongestants (pills or syrup): We do not recommend the use of any nasal decongestants that are taken by mouth for treatment of a cold, although an FDA panel has found two ingredients, pseudoephedrine and phenylephrine, safe and effective. These decongestant ingredients are in the OTC drugs Actifed and Sudafed and others of the prescription cough and cold drugs presented on this site. The reason we do not recommend them is that they all contain large amounts of amphetamine-like drugs that can increase your heart rate and blood pressure. In addition, they can make you jittery and keep you awake. By using nose drops or spray, for one to three days (no more), you get less than 1/25 as much of these drugs—and just in your nose where they are needed, instead of throughout your system as you do when you take these drugs by mouth.

Antihistamines: Although the FDA has tentatively approved these drugs for colds, we do not recommend the use of the following for treatment of a cold, largely because they are ineffective for this purpose: CHLOR-TRIMETON and Dimetane (OTC) or any of the prescription antihistamines.

The most widely read book on drugs, a standard reference for doctors called The Pharmacological Basis of Therapeutics, says this about the use of antihistamines for treating the common cold: “Despite early claims and persistent popular belief, histamine-blocking drugs [antihistamines] are without value in combating the common cold.” Antihistamines also have a sedative effect.

Another reason to avoid unnecessary use of antihistamines is that older adults are more sensitive to their adverse effects. (See Adverse Drug Reactions)

Sore Throat

Sore throats are one of the leading causes of visits to doctors, with more than 10 million such visits a year. The only kind of sore throat that merits treatment with an antibiotic is a bacterial sore throat caused by group A beta-hemolytic streptococci, the so-called strep throat. Although only approximately 10% of adults seen by a doctor for a sore throat actually have strep throat, 75% of patients with sore throats seen by doctors are prescribed an antibiotic.[1] Though the likelihood that a sore throat in a child is a strep throat is somewhat higher, perhaps 25%, the majority of children are also treated with antibiotics. The risks of unnecessary antibiotic prescribing, discussed further in Antibiotics, include the adverse reactions, sometimes quite serious, to a drug that should have not been prescribed in the first place as well as unnecessary worsening of the already serious problem of antibiotic resistance.

As discussed in the section above about colds, a viral infection such as a cold is by far the most common cause of a sore throat. Although it is possible to have both a cold and a strep throat as the cause of your sore throat, most of the time it is one or the other, usually a viral infection. Among the clinical findings that make it more likely that you have a strep throat, rather than a viral sore throat, are the absence of a cough, the presence of not only a fever but chills and the presence of exudate (pus) on your tonsils. The most sensitive and specific test for a strep throat is the old-fashioned throat culture. Then, your doctor can write a prescription for an antibiotic, but it can be filled only if the throat culture turns out to be positive. The newer rapid diagnostic tests for strep are not quite as accurate but are in widespread use.

Cough: A Necessary Evil

Your lungs clean themselves constantly in order to maintain efficient breathing. Mucus normally lines the walls of the lungs and captures foreign particles, such as inhaled smoke and infecting virus particles. Hairlike cells (cilia) push this out of the lungs. Coughing adds an additional, rapid-fire means of removing unwanted material from the lungs.

A cough is beneficial as long as it is bringing up material, such as sputum (phlegm), from your airways and lungs. This is called a productive cough and is often seen with colds, bronchitis, and pneumonia. A dry, hacking, nonproductive cough, on the other hand, can be irritating and keep you awake at night. Cough can also be part of a chronic condition, such as asthma or emphysema, or it may be caused by cigarette smoking.

Cough resulting from a chronic condition should be evaluated by your doctor. You should also seek medical advice if your sputum (phlegm) becomes greenish, yellowish, or foul-smelling, if your cough is accompanied by a high fever lasting several days, if coughing or breathing deeply causes sharp chest pain, or if you develop shortness of breath. Any of the symptoms may indicate pneumonia. Anyone who coughs up blood should call a doctor.

Types of Coughs

A productive cough is useful in helping you to recover from a cold or flu. You should do what you can to encourage the clearance of material from your lungs by “loosening up” the mucus. This is the purpose of an expectorant, which thins secretions so that they can be removed more easily by coughing (or “expectoration”). The best expectorant is water, especially in warm liquids such as soup, which thins the mucus and increases the amount of fluid in the respiratory tract. A moist environment also helps this effort. You should drink plenty of liquids and, if you can, moisten the air in your home with a humidifier or plain water steamed by a vaporizer. A pan of water on the radiator can help in the winter.

A nonproductive cough, a dry cough bringing up no mucus, should not be treated with a cough suppressant, also called an antitussive, if it is only associated with a cold. A nonproductive cough associated with cancer, for example, that keeps you up at night or is extremely exhausting may call for the use of benzonatate (TESSALON). Cough suppressants should be used only in a single-ingredient product. Rest and plenty of fluids are also in order.

Cough Remedies (Not to Use)

Acute cough due to an upper respiratory tract infection is mild and self-limiting. Two of the most popular cough suppressants, dextromethorphan (DELSYM) and diphenhydramine (BENADRYL, SOMINEX FORMULA) have not been shown to be effective for this type of cough in children and adults and should not be used.

Another ingredient in prescription (and OTC) cough products that we recommend against using is the expectorant guaifenesin (in all Robitussin products). We believe guaifenesin lacks evidence of effectiveness in loosening secretions (see guaifenesin [MUCINEX, ROBITUSSIN]).

Fever, Headache, and Muscle Aches

Fever, headache, and muscle aches are sometimes companions of the common cold. They are best treated without drugs, with rest and adequate fluids, or with plain aspirin or acetaminophen. (A generic or store brand is as effective as heavily advertised brand names such as Genuine Bayer or Tylenol and generally costs less.)

Never give aspirin to a feverish person under 40 years old: he or she may have influenza rather than a cold. There is strong evidence that young people who take aspirin when they have flu (or chicken pox) have a greatly increased risk of later getting Reye’s syndrome. This is a rather rare but potentially fatal disease that often leaves its victims mentally impaired for life, if they survive.

Call your doctor if a fever climbs above 103 degrees Farenheit (39.4 degrees Centigrade), or if a fever at or above 100 degrees Farenheit (38 degrees Centigrade) lasts for more than four days. Under either of these circumstances, the patient probably does not have a cold.

When to Seek Medical Help

Seek Medical Help When Any of the Following Occur:

  • a fever greater than 101 degrees Farenheit (38.3 degrees Centigrade) accompanied by chills and coughing up thick phlegm (especially if greenish or foul-smelling)
  • sharp chest pain when taking a deep breath
  • coldlike symptoms that do not improve after seven days
  • any fever greater than 103 degrees Farenheit (39.4 degrees Centigrade)
  • coughing up blood
  • a painful throat with any of the following
  1. pus (yellowish-white spots) on the tonsils or the throat
  2. fever greater than 101 degrees Farenheit (38.3 degrees Centigrade)
  3. swollen or tender glands or bumps in the front of the neck
  4. exposure to someone who has a documented case of strep throat
  5. a rash that came during or after a sore throat
  6. a history of rheumatic fever, rheumatic heart disease, kidney disease, or chronic lung disease such as emphysema or chronic bronchitis


 Inhaled steroids for asthma have been available in the United States mainly in pressurized metered-dose inhalers, which require a propellant. The chlorofluorocarbon (CFC) propellants in these formulations are being changed for environmental reasons. Dry-powder inhalers, which are activated by inhalation, do not require a propellant, and people who have difficulty with hand-breath coordination find them easier to use.

If you have difficulty with hand-breath coordination, talk to your doctor about a dry powder inhaler.