Katherine Lee, PharmD

The pharmacy community is justifiably skeptical of many products that claim to treat the common cold. A paucity of convincing evidence suggests that any of these options have better success than a placebo or the old standby of plenty of fluids and rest. But we all dread waking up with a scratchy throat and a stubbornly stuffed-up nose. Who knows how long it will last? Not forever, of course, but any length of time with a cold is too long. The mainstay products, such as antihistamines, decongestants, and cough suppressants, have at least some benefit when it comes to reducing pesky cold symptoms, but patients will still experience several days of congested misery. Luckily, relief might come from a few unexpected products.

To this day, the data showing that cough suppressants such as dextromethorphan work better than a placebo are inconsistent at best. However, honey is a common household item that might actually have some effect.

 This natural product contains many vitamins, including A, B, C, E, and K, as well as amino acids and proteins. As a compound, honey possesses antimicrobial and antioxidant properties, which vary based on geographical location. Added to comforting hot beverages such as tea, honey has the potential to decrease inflammation and inhibit any microbes that might be festering in the throat. Although no high-quality studies have evaluated the effect of honey compared with commonly marketed cough treatments, the CHEST expert panel makes a cautious statement suggesting honey as reasonable option for adults and children with a common cold and cough.

 No one can say with evidenced-based certainty that honey is better than other products, but adding honey to a soothing mug of tea could provide a needed boost.

The mineral zinc is another interesting option for treating a cold. Zinc is thought to inhibit rhinovirus replication, which theoretically can not only treat a cold but also minimize symptoms. Enough studies have been done to conduct systematic reviews, yielding mixed results. Zinc lozenges are the dosage form of choice of most investigators. In a large meta-analysis of 13 individual studies comparing zinc lozenges or syrups with a placebo, results showed that zinc significantly reduced the duration of a cold by 1.65 days.

 A day less of being sick is certainly nothing to sneeze at. Although zinc lozenges are an easy and quick solution, no official recommendations support the use of zinc. However, the lozenges are rarely associated with negative events other than tasting terrible, so those who can stomach them may find zinc to be a viable way to shorten a cold’s duration by a day or so.

For those amenable to a nasal spray, cromolyn offers another promising option for faster recovery. In a placebo-controlled, randomized study comparing nasal cromolyn with placebo, participants rated their symptoms for 7 days of treatment.

 Reported symptoms declined significantly by day 5. This is a promisingly consistent trend toward improvement, especially with cough and the raspy voice associated with colds. The benefit was maximized if the cold symptoms were particularly nasty. The adverse effects of nasal cromolyn are mild, making this a relatively risk-free option.

Despite sparse evidence to support many OTC cold remedies, we can glean from the available information that at least a few options could shorten the duration of the misery caused by a cold. However, nothing can replace old-fashioned fluids and rest, but remember to tell patients to add a little bit of honey to that soothing mug of tea.

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Articles

A few unexpected products, such as honey, could end the misery more quickly than expected.

Help Patients Shorten the Duration of a Cold

Antibiotics are often temporary but still common additions to many patients’ medication lists.

Although most antibiotic courses are limited to a week or less time, the adverse effects should be a key consideration. Pharmacists can discuss and monitor for adverse effects (AEs) and identify those at higher risk. Most AEs are not severe, but some are serious enough to warrant consideration when selecting antibiotic therapy.

Diarrhea is the most common complaint after a course of broad-spectrum antibiotics because of the inevitable alteration of the baseline gut microbiota. The condition is usually self-limiting but problematic in patients at risk for dehydration or 

 infection. Most patients who experience antibiotic-associated diarrhea are older than 70 years, have comorbid conditions, and are on pharmacologic treatments that predispose them to developing diarrhea. The most common risk factors include chronic proton pump inhibitor use, diabetes, and multiple antibiotic therapies.

 Penicillin has the highest prevalence of antibiotic-associated diarrhea, followed by quinolones and cephalosporins. A recent study also demonstrated that macrolides, regardless of the reason for use, were associated with a marked increase

 is a more severe gastrointestinal AE associated with antibiotic use. Similar to and sometimes related to antibiotic-associated diarrhea, 

arises because of a shift in the balance of the gut microbiota. Specifically, 

 is recognized as an important genus for maintaining gut regularity. When 

 is eradicated after broad-spectrum antibiotic use, 

is given the opportunity to overgrow and become the predominant gut flora.

 Clindamycin remains well known for its increased risk of leading to 

 infection, though fluoroquinolones have also become known to play a role in diarrhea associated with 

 Corrected QT interval (QTc) prolongation, associated with torsade de pointes, is a very rare but serious AE that has received a lot of attention in recent years. Despite the condition’s rarity, the FDA requires that all new drugs undergo specific testing for risk of QTc prolongation before approval. Antibiotics occupy a significant portion of the list of drugs with a known risk of QTc prolongation.

CredibleMeds maintains an updated list of evidence regarding drugs with a known or possible risk of QTc prolongation. Fluoroquinolones, macrolides, and trimethoprim have been minimally associated with QTc prolongation in the general population. However, patients who exhibit baseline prolonged QTc or have predisposing factors for dysrhythmia, such as electrolyte abnormalities and heart disease, should receive particular attention.

Fluoroquinolones are also characterized by the rare occurrence of tendon rupture, an AE that warrants a class-wide black box warning. The Achilles tendon is the most common site for such ruptures, but other major tendons have also been implicated.

 Levofloxacin holds the most evidence for the highest risk of leading to tendinopathy and tendon rupture.

 Patients at highest risk for tendon rupture include women and individuals older than 60 years. Most notably, concurrent glucocorticoid use is also associated with an increased risk of tendon rupture. For this reason, patients who require dual treatment with a fluoroquinolone and a steroid should be considered for alternative therapy.

 This AE may be mitigated by carefully adjusting the dose in renal impairment and limiting the duration of therapy to minimize exposure.

Elseviers M, Van Camp Y, Nayaert S, Duré K, Annemans L, Tanghe A, Vermeersch S. Prevalence and management of antibiotic associated diarrhea in general hospitals [published online Mar 17 2015]. 

Hansen M, Scot A, McCullough A, Thorning S, Aronson J, Beller E, Glasziou P, Hoffmann T, Clark J, Del Mar C. Adverse events in people taking macrolide antibiotics versus placebo for any indication. [published online Jan 18 2019] 

Britton R, Young V. Role of the intestinal microbiota in resistance to colonization by Clostridium difficile [published online Feb 4 2014]. 

Deshpande A, Pasupuleti V, Thota P, Rolston D, Sferra T, Hernandez A, Donskey C. Community-associated Clostridium difficile infection and antibiotics: a meta-analysis. [published online Apr 25 2013]. 

Pépin J, Saheb N, Coulombe M, Alary M, Corriveau M, Authier S, Leblanc M, Rivard G, Bettez M, Primeau V, Nguyen M, Jacob C, Lanthier L. Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec. [published online Sep 20, 2005]. 

Buss V, Lee K, Naunton M, Peterson G, Kosari S. Identification of Patients At-Risk of QT Interval Prolongation during Medication Reviews:

	A Missed Opportunity? [published online Dec 10, 2018]. 

Heemskerk C, Pereboom M, van Stralen K, Berger F, van den Bemt P, Kuijper A, van der Hoeven, Mantel-Teeuwisse A. Risk factors for QTc interval prolongation. [published online Nov 22, 2017]. Eur J Clin Pharmacol. doi:10.1007/s00228-017-2381-5

Pourmand A, Mazer-Amirshahi M, Chistov S, Sabha Y, Vukomanovic D, Almulhim M. Emergency department approach to QTc prolongation. [published online Aug 19 2017]. 

Mehlhorn A, Brown D. Safety concerns with fluoroquinolones. [published online Oct 2 2007]. 

Bidell M, Lodise T. Fluoroquinolone-Associated Tendinopathy: Does Levofloxacin Pose the Greatest Risk? [published online Jun 11 2016]. 

Wise B, Peloquin C, Choi H, Lane N, Zhang Y. Impact of age, sex, obesity, and steroid use on quinolone-associated tendon disorders [published online Sep 28 2012]. 

Pharmacists are well positioned to monitor patients and identify those who might be at higher risk for adverse events.