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Does avoiding medication that alleviates symptoms shorten the length of a cold?

Does avoiding medication that alleviates symptoms shorten the length of a cold?



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People use over the counter (OTC) medications to relieve symptoms of the common cold.

However, these symptoms are part of the immune response, right? They are driven by the body responding to the virus and attempting to make the body less habitable and thus easier to kill it off.

Do OTC medications that reduce cold symptoms cause the cold to persist longer? Should such medications be avoided if the goal is to reduce cold duration rather than symptoms?


It is plausible but by no means established that antipyretics (fever suppressors) in particular could increase the duration of infection/symptoms, because fever is part of a functional immune response.

From Graham et al 1990 (a small [n=56] randomized trial of the use of antipyretic pain relievers in volunteers experimentally infected with rhinovirus):

Use of aspirin and acetaminophen was associated with suppression of serum neutralizing antibody response (P less than .05 vs. placebo) and increased nasal symptoms and signs (P less than .05 vs. placebo)… There were no significant differences in viral shedding among the four groups, but a trend toward longer duration of virus shedding was observed in the aspirin and acetaminophen groups.

In other words, it looked like the people who took aspirin or acetaminophen had weaker immune responses and more cold symptoms. They might have been infectious for slightly longer, but it's hard to tell (also, duration of infectiousness is not the same as the duration of symptoms… )

However, a review (Kim et al 2013) concluded that NSAIDs (non-steroidal anti-inflammatory drugs) slightly (but non-significantly) reduced the duration of illness.

In a pooled analysis, NSAIDs did not significantly reduce the total symptom score (SMD -0.40, 95% CI -1.03 to 0.24, three studies, random-effects model), or duration of colds ([mean difference] -0.23 [days], 95% CI -1.75 to 1.29, two studies, random-effects model) [emphasis added]

Here is the figure from that analysis:

"Common cold" is often considered synonymous with rhinovirus infection, but may also include mild influenza infections. An observational study on influenza A and two other infections (Graham et al 2000) found

There was a striking correlation between antipyretic therapy and duration of illness in subjects infected with influenza A and S. sonnei, but not R. rickettsii… Multivariate analysis suggested that antipyretic therapy prolonged illness in subjects infected with influenza A, but its use was the result of prolonged illness in those infected with S. sonnei.

In other words, to the extent that one can really distinguish causality in an observational study, it seemed that taking antipyretics made influenza illness longer, but that causality went in the other direction for S. sonnei (i.e., people took more antipyretics when they were sick for longer).

The usual caveats associated with small studies and researcher degrees of freedom apply when interpreting the results of these studies…


  • J Infect Dis. 1990 Dec;162(6):1277-82 Adverse effects of aspirin, acetaminophen, and ibuprofen on immune function, viral shedding, and clinical status in rhinovirus-infected volunteers.
  • Pharmacotherapy 2000 (20), 1417-1422. (doi:10.1592/phco.20.19.1417.34865) Effect of antipyretic therapy on the duration of illness in experimental influenza A, Shigella sonnei, and Rickettsia rickettsii infections.
  • Cochrane Database Syst Rev. 2013 Jun 4;(6):CD006362. doi: 10.1002/14651858.CD006362.pub3. Non-steroidal anti-inflammatory drugs for the common cold. Kim SY, Chang YJ, Cho HM, Hwang YW, Moon YS.

The common cold as a clinical syndrome is not any particular viral infection, but a cluster of symptoms that follow a stereotypical course. It's generally associated with an initial viral infection and you can isolate infectious particles early in the course of the illness, but by the time most people go to the doctor there is no active infection. Because of this, care for a common cold is directed at the symptoms. You could even say (and I do) that the common cold is the symptoms, not the infection.

The development and resolution of many common cold symptoms are unrelated to direct infection. Cough, for example, when associated with the common cold, is not due to infection directly, but reactive inflammation, and is one of the symptoms that lingers the longest. Treatment limiting postnasal drip and, in patients with reactive airway disease, any associated asthma flare up can shorten the length of the illness.

So, no, treating the symptoms in the case of the common cold is not a bad idea, and does not cause the disease to last longer. It may even shorten the disease course.

You can see some of these principles discussed in these clinical practice guidelines and in this review of the pathogenesis of one of the viruses most often associated with the common cold syndrome.

The general principles in this answer are discussed in Cecil Medicine Ch. 369 and Bennett Prinicples and Practice of Infectious Disease Ch 58. If you're interested in the common cold, I highly recommend reading both of these chapters. Though they were from now dated earlier editions, these chapters really helped me get a grasp on how to approach clinical syndromes in infectious disease when I was starting out.

Note:

See the comments below for valid criticisms of this answer. While the common cold is simple in many ways, good evidence on this syndrome is not simple or common. Host -pathogen interactions are variable at best, and there are thousands of viral serotypes that cause the common cold (many of which cause other illnesses too). My answer here is a synthesis of treatment recommendations and a clinical approach. As @anongoodnurse says, this is probably not a good way to answer a layperson rather than a serious student of human biology via clinical medicine. The summary is pretty simple. If you use medicine that is safe to make someone with a cold feel better, you've taken care of that person's cold. If you don't have the access or background knowledge to digest Cecil and Bennett, believing this requires you to take an anonymous internet typist's word for it. Because of that, it may not be a good SE answer.


Common side effects

These side effects happen in more than 10 in 100 people (10%). You might have one or more of them. They include:

Lung infection

You might develop a cough or breathing problems. This could be due to infection, such as pneumonia or inflammation of the lungs (pneumonitis). Let your doctor or nurse know straight away if you suddenly become breathless or develop a cough.

Inflammation of the nose and throat

Your nose and throat could become swollen and sore.

Breathlessness

You might be breathless and look pale due to a drop in red blood cells. This is called anaemia.

Risk of infection

Increased risk of getting an infection is due to a drop in white blood cells. Symptoms include a change in temperature, aching muscles, headaches, feeling cold and shivery and generally unwell. You might have other symptoms depending on where the infection is.

Infections can sometimes be life threatening. You should contact your advice line urgently if you think you have an infection.

Bruising and bleeding

This is due to a drop in the number of platelets in your blood. These blood cells help the blood to clot when we cut ourselves. You may have nosebleeds or bleeding gums after brushing your teeth. Or you may have lots of tiny red spots or bruises on your arms or legs (known as petechiae).

Loss of appetite and weight loss

You might not feel like eating and may lose weight. It is important to eat as much as you can. Eating several small meals and snacks throughout the day can be easier to manage. You can talk to a dietitian if you are concerned about your appetite or weight loss.

Difficulty sleeping

It can help to change a few things about how you try to sleep. Try to go to bed and get up at the same time each day and spend some time relaxing before you go to bed. Some light exercise each day may also help.

Dizziness and headaches

Let your doctor or nurse know if you have headaches. They can give you painkillers. Don’t drive or operate machinery if you feel dizzy.

Diarrhoea or constipation

Tell your doctor or nurse if you have diarrhoea or constipation. They can give you medicine to help.

Feeling or being sick

Feeling or being sick is usually well controlled with anti sickness medicines. Avoiding fatty or fried foods, eating small meals and snacks, drinking plenty of water, and relaxation techniques can all help.

It is important to take anti sickness medicines as prescribed even if you don’t feel sick. It is easier to prevent sickness rather than treating it once it has started.

Tummy (abdominal) pain

Tell your treatment team if you have this. They can check the cause and give you medicine to help.

Rash, itchy skin

Skin problems include a skin rash, dry skin and itching. This usually goes back to normal when your treatment finishes. Your nurse will tell you what products you can use on your skin to help.

Joint and muscle pain

You might feel some pain from your muscles and joints. Speak to your doctor or nurse about what painkillers you can take to help with this.

High temperature

If you get a high temperature, let your health care team know straight away. Ask them if you can take paracetamol to help lower your temperature.

Tiredness

You might feel very tired and as though you lack energy.

Various things can help you to reduce tiredness and cope with it, for example exercise. Some research has shown that taking gentle exercise can give you more energy. It is important to balance exercise with resting.

Chest pain

You might get pain in your chest and shortness of breath. Contact your advice line or tell your doctor if this happens.

Redness, pain and swelling at the injection site

Tell your nurse if you notice any signs of redness or irritation around the injection site.


About vitamin C

Our bodies don't make vitamin C, but we need it for immune function, bone structure, iron absorption, and healthy skin. We get vitamin C from our diet, usually in citrus fruits, strawberries, green vegetables, and tomatoes. The Recommended Dietary Allowance for men is 90 milligrams (mg) per day, and for women, it's 75 mg per day.

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4. Eat plenty of produce and probiotics.

Eating an immune system-friendly diet goes a long way during flu season, suggests Appel. Focus your eats on antioxidant-rich fruits and vegetables (like blueberries, tomatoes, and sweet potatoes), which basically strengthen your body&rsquos inner flu shield. Your goal: Make sure there&rsquos something rainbow-colored (that&rsquos not a Skittle) on your plate every time you eat.

Loading up on probiotic-rich fermented foods&mdashlike yogurt, kefir, sauerkraut, and tempeh&mdashcan also support your immune system by nourishing your gut, Appel says. Aim to put something fermented in your mouth every single day.


The Top Five Cold Remedies That Do Not Work

One of my daughters caught a cold last week, and now she's given it to me. We’re giving ourselves the best treatment known to science: rest. But to judge from the products offered at our pharmacies, you’d think there were dozens of options to treat a cold. In local pharmacies and in the medicines aisle at my local grocery store, I’ve found row after row of colorful packages, claiming to relieve cold symptoms, shorten the duration of the common cold, and more.

Some of these medications actually do treat symptoms, but none of them cure a cold. But mixed among them—sometimes side by side with real medicines—I found several products that don’t work at all.

How can a drug manufacturer get away with this? Simple: the products that don’t work are either supplements or homeopathic products. The manufacturers of both these types of “medicines” have successfully lobbied Congress to pass laws that exempt them from FDA regulation. Supposedly they aren’t allowed to make direct claims to cure or treat disease, but unless you read the wording on their packages very carefully, you’d never notice. (Note to older adults: bring your reading glasses to the pharmacy section!)

The secret cure for the common cold: chicken noodle soup. Source: Wikipedia

Most important for consumers: if a treatment says it’s homeopathic, then its ingredients do not have to be shown effective. “Homeopathic” simply means that the ingredients are listed on the Homeopathic Pharmacopoeia, a list maintained by homeopaths themselves. And if it contains supplements or vitamins, they too are exempted from regulation by the FDA, under a law known as DSHEA.

So next time you go searching for something to take for your cold, or for your child’s cold, here are the top 5 cold remedies you should not buy:

1. Zicam contains zinc as its active ingredient. There has been some evidence to suggest that taking zinc right at the onset of a cold might shorten its duration a little bit, from 7 days to 6. But as Dr. Terence Davidson from UC San Diego explained, if you look at the more rigorous studies, the effect vanishes. Zinc turns out to have some worrisome side effects, too. Zicam's nasal spray and gel versions were linked to a serious loss of the sense of smell (anosmia), which led the FDA to issue a warning letter in 2009. Zicam responded by withdrawing the product for a time, but their website now says "A clinical link between the Zicam® products and anosmia was not established." Strictly speaking, this is correct, but there have been published reports suggesting a link, such as this one from 2009.*

Zicam’s website makes the misleading claim that “all of our Zicam® products are regulated by the FDA.” This is a common ploy of homeopathic drugmakers, claiming the FDA regulates them because the FDA could step in (as they've already done with Zicam) if consumers are being harmed. Unlike real drugs, though, Zicam has not been evaluated by the FDA for effectiveness or safety.

2. Airborne. You can find this in the cold remedy section many pharmacies (I did), but Airborne doesn’t cure anything. It’s a cleverly marketed vitamin supplement with no scientific support for any health benefits. How do they get away with it? Actually, Airborne paid $23 million back in 2008 to settle a class-action lawsuit over its advertising. They had been calling Airborne a “miracle cold buster.” According to the Center for Science in the Public Interest’s David Schardt:

Airborne is basically an overpriced, run-of-the-mill vitamin pill that’s been cleverly, but deceptively, marketed.

After the lawsuit, Airborne modified their packaging, which now claims only that it “helps support your immune system.” This is one of those vague claims that supplement makers love, because it doesn't really mean anything. Airborne's products also now include a disclaimer:

These products are not intended to diagnose, treat, cure, or prevent any disease.

So what the heck are they doing in the “cold medicines” section of the store?

3. Coldcalm is a homeopathic preparation sold by Boiron, one of the world’s largest manufacturers of homeopathic remedies (including Oscillococcinum, an almost laughably ineffective flu remedy). It claims on the package to relieve cold symptoms. What’s in it? A dog’s breakfast of homeopathic ingredients, including belladonna, about which NIH says:

Belladonna is UNSAFE when taken by mouth. It contains chemicals that can be toxic.

Another ingredient is pulsatilla, which “is highly toxic, and produces cardiogenic toxins and oxytoxins which slow the heart in humans.” Neither belladonna nor pulsatilla relieves cold symptoms.

Being homeopathic, these ingredients are highly dilute, but I think I’ll pass on Coldcalm.

4. Umcka is another homeopathic preparation that claims to “shorten the duration of common cold” and “reduce severity of cold symptoms.” Sounds pretty good—if only it were true. Umcka’s active ingredient is a plant extract called pelargonium sidoides, an African geranium. Interestingly, there have been a few experiments on this extract, some of which showed a small positive effect. However, a review of these studies reported that their quality was "very low," that all of them were conducted by Umcka itself, and that all of them were conducted in the same region of Russia. And remember: homeopathic preparations are so dilute that they contain little, and sometimes none, of the active ingredient.

5. Antibiotics. Okay, these are real medicine, and you can’t buy them over the counter at your pharmacy. But Americans take them in huge quantities to treat the common cold. The problem is, antibiotics don’t work for colds.

When my daughter told her friends she had a cold, they wanted to know why she didn’t go to the doctor. Of course, doctors can’t do anything about a cold, and going to a doctor’s office just puts other patients at risk. My daughter knows this. But her friends were astonished to hear that we never take her to the doctor for a cold. It turns out that most of them had been to doctors many times for colds, often coming away with a prescription for antibiotics.

Antibiotics treat bacterial infections, not viruses. Taking antibiotics unnecessarily can be bad for you: besides wiping out your gut flora, it increases the risk that bacteria will develop drug resistance. Perhaps if we changed the name to "antibacterials," doctors would stop prescribing them for viruses.

I found Zicam, Airborne, Umcka, and Coldcalm for sale at Walgreens and Walmart. CVS and RiteAid don’t carry Umcka (good for them!) but do sell the others.

When you get a cold, you develop immunity to it and you won’t catch it again.We keep getting colds because they're caused by more than 100 different viruses, most of them nasty little buggers that continually circulate in our population. Each time you catch a cold, you’re getting a brand new one. The only consolation is that once you’re over it, you won’t get that one again.

So if you get a cold this winter, save your money. Stay home, rest and drink plenty of fluids. And I have it on good authority that there is one treatment for the common cold that’s inexpensive, widely available, and really, really works: chicken soup.

*Update, 6 Dec: in response to my inquiry, Zicam's manufacturer, Matrixx Initiatives, sent me some additional information. They pointed out that subsequent studies have not supported a link between Zicam and anosmia (loss of the sense of smell), and also that they permanently discontinued Zicam intranasal gel products ("Cold Remedy Nasal Gel and Cold Remedy Gel Swabs) in 2009, "despite the absence of any credible scientific data pointing to a potential link." They also argue that "the efficacy of zinc-based formulations is primarily a function of bioavailable dose" and that "Zicam products are formulated to ensure availability of the zinc." Arguing in favor of Zicam's benefits, they pointed to several studies that I'd already read, and I remain unconvinced and, as I pointed out above, Matrixx does not have to prove efficacy to the FDA because they are selling Zicam as a homeopathic preparation, which allows them to avoid FDA regulation.


Taking Zinc Can Shorten Your Cold. Thank A 91-Year-Old Scientist For The Discovery

Your body needs trace amounts of zinc for cell division and other basic biology. Nobody's sure how it works to shorten colds.

The common cold is a top reason for missed work and school days. Most of us have two or three colds per year, each lasting at least a week.

There's no real cure, but studies from the last several years show that some supplement containing zinc can help shorten the duration of cold symptoms by up to 40% — depending on the amount of the mineral in each dose and what it's combined with.

Zinc has an interesting back story. It wasn't even acknowledged as an essential mineral for human health until the 1970s. But that changed thanks to the work of Dr. Ananda Prasad — a 91-year-old doctor who, decades ago, had a hunch that led to a better understanding of zinc's role in immunity.

Back in the 1960s Prasad was studying a group of young men in Egypt who had not grown to normal heights and remained underdeveloped in other ways, too. Prasad wondered if the problem might be a lack of zinc.

When Prasad gave them zinc supplements, the men grew significantly taller.

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"I couldn't believe it," he says. Prasad had never expected such significant growth.

Some scientists challenged his findings, at the time, questioning the idea that zinc deficiency could even occur in humans. "It was controversial," Prasad says.

But he pressed on with his research and began to document the ways zinc influences immunity.

Eventually, in the 1970's, the National Academy of Sciences declared zinc an essential mineral, fundamental to many aspects of cell metabolism. NAS established a recommended daily allowance, which is the daily amount that's sufficient for good nutrition. (Most of us today get plenty of zinc from foods such as beans, nuts, whole grains and fortified cereals.)

Prasad says he felt vindicated by this action. "Absolutely," Prasad told us from his home in Michigan, where he's a researcher and professor at Wayne State University School of Medicine in Detroit.

What came next in his career may be just as surprising. Prasad had demonstrated that zinc had an effect on immunity — so he figured that it might help against a ubiquitous scourge — the common cold.

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To test this theory, he collaborated with a scientist at the University of Michigan — who was skeptical.

"When I first heard this — I actually told his research assistant: I think he's losing it," recalls James T. Fitzgerald, who has expertise in designing research studies.

Fitzgerald agreed to help with a double-blind, placebo-controlled trial. They identified participants in the Detroit area who had developed colds and gave them zinc lozenges. Neither the participants nor the researchers knew who was given the real thing, and who was given the placebo.

"Lo and behold, when I did the analysis it indeed did shorten common cold symptoms by about two or three days, " Fitzgerald says. "I was stunned by that result."

Zinc's been studied for years, and not all studies have pointed to a benefit, but that may be because of the dosage and composition of the lozenge used.

Most recently, a meta-analysis published in 2017 by Harri Hemilä at the University of Helsinki concludes that 80 to 92 milligrams per day of zinc, given at the onset of cold symptoms, reduced duration of the common cold by 33%.

The study finds that two different zinc compounds — zinc acetate and zinc gluconate — are both effective. And there's no evidence, the researchers say, that increasing those doses of zinc (to 100 milligrams per day or more) leads to any greater efficacy.

Great news. Nonetheless, "it's quite difficult to instruct patients," says Hemilä, the author of the meta-analysis. That's because zinc cold formulations sold at drugstores often contain multiple ingredients that can undercut the zinc's effectiveness. For instance, the lozenges "should not contain citric acid," Hemilä says, because it binds with the zinc in a way that keeps the mineral from being released. In addition, he says, the mechanism of action is not well understood, so scientists can't say exactly how it works.

The lozenge used in the Michigan study is not available commercially, Fitzgerald notes. "It was especially designed for the study."

So, do check each package's list of ingredients and the size of the zinc dose, the scientists recommend. Because not all products are going to help.

And remember, other common sense measures can help ease your cold symptoms too — like getting good sleep and drinking extra fluids -- or keep it from deteriorating into something worse.


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Larger doses of vitamin C may lead to a greater reduction in common cold duration

The relationship between vitamin C dosage and its effects on the duration of the common cold symptoms may extend to 6-8 grams per day.

Dozens of animal studies using different animal species have found that vitamin C significantly prevents and alleviates infections caused by diverse bacteria, viruses, and protozoa. Given the universal nature of the effect of vitamin C against various infections in different animal species, it also seems evident that vitamin C influences the susceptibility to, and the severity of infections in humans. However, the practical importance of vitamin C in human infections is not known.

The common cold is the most extensively studied infection regarding the effects of vitamin C. The majority of controlled trials have used a modest dosage of only 1 g per day of vitamin C. The pooled effect of all published studies has shown a statistically highly significant difference between the vitamin C and placebo groups, which indicates a genuine biological effect. However, the optimal doses and the maximal effects of vitamin C on the common cold are unknown. The trials that used doses higher than 1 g per day usually found greater effects than trials with exactly 1 g per day, which suggests a dose dependent effect. Nevertheless, definitive conclusions cannot be made from such a comparison because of numerous confounding differences between the trials. The most valid examination of dose-response is therefore within a single trial that has randomly selected trial groups with different vitamin C doses, so that exposure to viruses is similar and the outcome definition is identical in the study groups.

Dr. Harri Hemilä from the University of Helsinki, Finland, analyzed the findings of two randomized trials each of which investigated the effects of two vitamin C doses on the duration of the common cold. The first trial administered 3 g/day vitamin C to two study groups, 6 g/day to a third group, and the fourth group was administered a placebo. Compared with the placebo group the 6 g/day dose shortened colds by 17%, twice as much as the 3 g/day doses did. The second trial administered 4 g/day and 8 g/day vitamin C, and placebo to different groups, but only on the first day of the cold. Compared with the placebo group, the 8 g/day dose shortened colds by 19%, twice as much as the 4 g/day dose did. Both studies revealed a significant dose-response relationship between the vitamin C dosage and the duration of the common cold. The dose-response relationship in these two trials was also quite linear up to the levels of 6-8 g/day, thus it is possible that even higher doses may lead to still greater reductions in the duration of common cold. Dr. Hemilä notes that there have been proposals that vitamin C doses should be over 15 g/day for the best treatment of colds, but the highest doses that have so far been investigated in randomized trials have been much lower.

Dr. Hemilä concludes that "given the consistent effect of vitamin C on the duration of colds, and its safety and low cost, it would be worthwhile for individual common cold patients to test whether therapeutic 8 g/day vitamin C is beneficial for them. Self-dosing of vitamin C must be started as soon as possible after the onset of common cold symptoms to be most effective." Dr Hemilä also states that further therapeutic trials should be carried out to investigate the dose-response relation in the region of over 8 g/day of vitamin C.


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