OTC Case Studies: Common Cold

Case 1: Pediatric Colds

TJ, a 3-year-old boy, is brought to the pharmacy by his grandmother because he has had a runny nose, mild cough, and nasal congestion for the past 2 days. He does not have a fever, is eating and drinking normally, and is active during the day. He does have trouble going to sleep because he is coughing more at night. His grandmother has been giving him honey and is wondering what cough or cold medicine could help him sleep better. How can she help him?

A: The FDA does not recommend the use of OTC cough and cold medicines in children younger than 2 years due to the risk of severe, potentially life-threatening adverse effects. Most drug manufacturers have updated their labels to state that their products are not recommended for children under 4 years. Therefore, counseling should focus on supportive measures: rest, comfort, fluids, use of a cool-mist humidifier and saline nasal spray or drops with gentle suction, and honey for throat and cough relief. Honey is generally considered safe and potentially effective for coughs in children. To reduce nighttime cough, she can give TJ 2.5 to 10 mL at bedtime. In general, symptoms usually improve within 7 to 10 days; however, she should be counseled to take TJ to his pediatrician if fevers develop, he has difficulty breathing, symptoms extend beyond 1 week, or cough or other symptoms worsen.¹

Case 2: Sore Throat and Fever

FS, a 13-year-old girl, comes to the pharmacy with her mother, reporting a sore throat for the past 3 days, a fever (temperature range, 100.8-101.2 °F), and pain upon swallowing. She says she has no cough, congestion, or runny nose. She has been gargling with salt water and using cough drops, and she has taken two 325-mg acetaminophen tablets every 6 hours over the past couple of days. She asks whether any other OTC remedies will help or whether she might need an antibiotic. The pharmacy participates in a test-to-treat program, and a rapid strep test is performed in the consultation room. The result is positive for group A streptococcus. FS has no known drug allergies and weighs 83 lb. What should be the recommendation?

A: The symptoms FS is experiencing match the results from the rapid strep test. Group A streptococcus is common in 20% to 30% of pharyngitis episodes in children. An antibiotic is recommended to shorten the duration of symptoms, reduce the risk of transmission, and decrease the development of complications. Because FS does not have any allergies to penicillins, she can be prescribed either penicillin V 500 mg twice daily or amoxicillin 500 mg twice daily for 10 days. Supportive measures such as rest, saltwater gargles, and cough drops can also be recommended for pain relief.²

Case 3: OTC Medications for Patients With Hypertension

PR, a 54-year-old woman, comes to the pharmacy with an OTC cough and cold medication marketed for individuals with high blood pressure that contains chlorpheniramine and dextromethorphan. She states she has had nasal congestion, a mild headache, and a sore throat that started 2 days prior. She asks whether the medication is a good choice or whether she should take a stronger decongestant, such as pseudoephedrine, to help with the congestion. Her medical history includes hypertension, atrial fibrillation, and type 2 diabetes, and her medications include warfarin, losartan, hydrochlorothiazide, metoprolol, and metformin. What would you recommend?

A: Decongestants such as pseudoephedrine are not optimal choices because they will raise blood pressure and potentially worsen her atrial fibrillation. Because of PR's symptoms, the product she has chosen will not be beneficial. Chlorpheniramine is an antihistamine, and dextromethorphan is a cough suppressant. Counseling should emphasize safer symptom relief such as saline sprays or rinses and humidifiers. For headache and sore throat, acetaminophen is a safer choice than nonsteroidal anti-inflammatory drugs due to the potential interaction with warfarin. If she takes higher doses of acetaminophen for multiple days (>2 g/day), her international normalized ratio may be affected. Additionally, the importance of avoiding multisymptom cold products is an important counseling point. She should be referred to her provider if congestion worsens or if she has high or uncontrolled fevers.^3-5

Case 4: Oxymetazoline Nasal Spray

TK, a 42-year-old man, presents to the pharmacy, reporting nasal congestion, scratchy throat, and mild cough for the past 4 days. He feels well otherwise and denies fever. He has no medical conditions and takes no medications. He mentions using oxymetazoline nasal spray for the past 2 days without much relief. What else can he do for relief?

A: The use of oxymetazoline nasal spray for more than 2 consecutive days is not recommended because it can lead to rebound congestion, making symptoms worse once the spray is stopped. To avoid this, TK should discontinue the nasal spray and consider an alternative, such as pseudoephedrine, which can help relieve nasal congestion without the risk of rebound effects. Pseudoephedrine can be used to treat nasal congestion, and he can choose the 30-mg or 120-mg strength. If his symptoms persist beyond 7 days, or if he develops any new symptoms (eg, fever or worsening congestion), he should follow up with his health care provider.⁶

REFERENCES

1. Scolaro K, Wilson J. Cough and cold. In: Pharmacotherapy First: A Multimedia Learning Resource. American Pharmacists Association; 2017. Accessed October 8, 2025. https://pharmacylibrary.com/doi/10.21019/pharmacotherapyfirst.uri_overview

2. Clinical guidance for group A streptococcal pharyngitis. CDC. August 5, 2025. Accessed October 8, 2025. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html?utm_source=chatgpt.com

3. Głowacka K, Wiela-Hojeńska A. Pseudoephedrine—benefits and risks. Int J Mol Sci. 2021;22(10):5146. doi:10.3390/ijms22105146

4. Multum C. Chlorpheniramine and dextromethorphan. Drugs.com. Updated July 9, 2025. Accessed October 8, 2025. https://www.drugs.com/mtm/chlorpheniramine-and-dextromethorphan.html?utm_source=chatgpt.com

5. Role of multi-symptom OTC self-care products for cold & flu symptom relief. Pharmacy Times. December 11, 2014. Accessed October 8, 2025. https://www.pharmacytimes.com/view/r677_december2014?utm_source=chatgpt.com

6. Eccles R. Substitution of phenylephrine for pseudoephedrine as a nasal decongesttant. an illogical way to control methamphetamine abuse. Br J Clin Pharmacol. 2007;63(1):10-4. doi:10.1111/j.1365-2125.2006.02833.x