I Have the Flu or a Cold. What Should I Take?

Woman with cold in blanket

How do you figure out exactly what’s wrong with you if you have symptoms common for a cold, the flu and COVID-19? It’s not always easy to tell. 

The table below helps you distinguish between the symptoms. Because the early signs of the flu and COVID are so similar, it’s probably best to get a test if you’re unsure of which it is.

 COLD V. FLU V. COVID-19

A Cold

  • Its onset is gradual and usually involves a “prodrome” stage, in which you have a sore throat or mild fatigue, pain and congestion.
  • No fever or low-grade fever
  • Sore throat, runny and stuffed-up nose, chills, body ache, fatigue and cough —  usually mild to moderate
  • Variable duration, but typically four to seven days
  • Differing recovery period, but typically 100% by Day 7 to 10

The Flu

  • Onset is sudden, usually within a few hours, and symptoms can be intense right away
  • Fever up to 102.5 F
  • Sore throat, runny and stuffed-up nose, chills, body ache, fatigue and cough, moderate to severe, and may include muscle aches and weakness
  • Duration of intense symptoms, typically four to six days; lingering weakness and fatigue, 10 to 14 days
  • Full recovery — feeling totally back to normal —  within three weeks

COVID-19

  • Onset: symptoms appear anywhere from two to 14 days after exposure, and usually start around Day 5
  • Cough, fever, loss of sense of smell, muscle aches, nausea and headache. The Centers for Disease Control and Prevention (CDC) offers an online symptom checker to help you determine if a COVID test is needed.
  • Recovery: a few days to a few weeks. Many patients report symptoms that linger for up to a year or more.

Should you stay at home?

All three infections are contagious by the time symptoms show up (some are even contagious beforehand). If possible, stay home to avoid spreading the virus to others. If you must venture out with a cold or the flu, avoid public places, wear a mask, limit direct contact with others and practice scrupulous handwashing and mouth covering when sneezing and coughing.

Do you need to call or see a doctor?

If you test positive for COVID, you may want to set up a telehealth visit with a healthcare provider to help monitor your condition. If you’re at high risk for severe disease, he or she may prescribe an infusion of monoclonal antibodies. 

Most people with a cold or the flu can skip a doctor or telehealth visit. However, there are a few exceptions. If a child under the age of 3 has a fever, it’s best to call your pediatrician. If you don’t recover within seven to 10 days, or symptoms worsen, it’s best to check in with a physician. Adults who are pregnant or over the age of 65 are at high risk of flu complications should see their doctor if symptoms seem worse than the average cold.

When is an antibiotic needed?

When your immune system is weakened by a severe viral infection, there’s a chance you could develop a secondary bacterial infection, causing pneumonia or bronchitis. You need a doctor to diagnose either one, and then prescribe antibiotics. These drugs won’t help if you only have a viral infection, and, in fact, they can harm you. Along with a host of side effects, antibiotics can increase your risk of dangerous infections like C. difficile (Clostridioides difficile), a bacteria that causes severe diarrhea and colitis. 

Nearly a third of antibiotic prescriptions are unnecessary. Taking them when unwarranted exposes you to their possible side effects, which can be diarrhea, nausea and potentially serious allergic reactions. More consequential, it also breeds antibiotic-resistant bacteria among the broader population, undermining the effectiveness of antibiotics when really needed. More than 35,000 people die annually from infections of antibiotic-resistant bacteria.

Which Non-prescription drugs work and which don’t, and which are safest?

Many over-the-counter drugs help relieve cold, flu and even mild COVID symptoms. There’s danger if you take too many drugs in combination and too much of any drug. It’s crucial to know when you might need a higher level of treatment, like hospital care or an infusion of monoclonal antibodies.

If you’re at high risk of COVID-19 complications

Medicines: The Food and Drug Administration (FDA) has authorized three brands of monoclonal antibody treatments for COVID-19: Regen-Cov (casirivimab and imdevimab), bamlanivimab and etesevimab, and sotrovimab.

Efficacy: These treatments have been shown to help prevent progression to severe disease and hospitalization, if given early in the disease course, that is, within the 10 days of developing symptoms.Risks: Because monoclonal antibodies were recently developed to treat COVID-19, not all the possible side effects are known. With any drug given by an infusion, there is a risk of bleeding, bruising and infection at the infusion site. Some patients have also had severe allergic reactions characterized by increased blood pressure, rapid or slowed heart rate, sweating, weakness, rash or confusion.

For These Symptoms: Body Aches and Fever

A fever doesn’t necessarily require treatment, as it is a part of your body’s effort to fight off the virus. The Mayo Clinic recommends treating a fever above 102 degrees F with ibuprofen or acetaminophen and calling your healthcare provider, if the fever lasts more than a few days.

Home remedies: A cool compress or sponge bath can help if your temperature spikes.

Medicines: Tylenol (acetaminophen), Advil (ibuprofen) and Aleve (naproxen

Efficacy and risks: All three ease body aches and reduce fever more or less equally.  However, acetaminophen is the safest, when used as directed. But taking even a little more than the daily max can harm the liver. Be aware that a combination cold and flu products may contain Tylenol already. So, if you’re taking combination products, don’t double dose by mistake by taking extra Tylenol.

Food for thought: : Taking the over-the-counter analgesic Tylenol may do more than just relieve your pain. It may also make you less likely to empathize with others in pain. A study published in the journal Social Cognitive and Affective Neuroscience conducted by researchers at Ohio State University reported on two experiments that found that when subjects who took acetaminophen, the active ingredient in Tylenol and found in more than 600 medicines, they thought those those talking about pain experienced less pain and suffering when compared to those who took no painkiller. Advil and Aleve can cause intestinal bleeding, and they have been linked to an increase in the risk of heart attack and kidney damage, primarily when taken in high doses for long periods.

If you’re pregnant, there’s a chance that Tylenol (acetaminophen) may increase the risk of developmental disorders in your child. However, having a fever can also pose risks to your baby. It’s best to weigh the dangers of exposing your baby to the treatment against those of exposing him or her to your illness with your OB/GYN.

Ask a doctor or pharmacist first if you are taking aspirin to prevent a heart attack or stroke, because naproxen, Aleve, may decrease the benefit of aspirin.


For These Symptoms: Congestion

Home remedies: chicken soup! Hot liquid and steam from any broth-based soup may help open up swollen airways and thin out mucus. It also soothes a sore throat, tastes good and nourishes you.

Neti pots and nasal irrigation: Yes, they can be messy to use, but they do ease congestion.

Steam inhalation: Warm-water vapor helps loosen mucus, which feels good. Though it’s unclear whether that change translates into reduced congestion, many people swear by it. Try making your own home sauna by heating water (don’t boil, because that’s too hot), put a towel over your head as you lean carefully over the water. The towel will trap the steam, so it concentrates toward your sinuses. Be careful. If it feels too hot, it is.  A hot shower may be safer than putting your head over a piping-hot pot of water.

Medicines:

  • Afrin, Dristan Mucinex Sinus-Max Nasal Spray, Vicks Sinex Severe Nasal Spray (oxymetazoline nasal spray)
  • Equate Congestion Suphedrine PE Nasal Decongestant, Sudafed PE Congestion (phenylephrine) 
  • Sudafed 12 Hour (pseudoephedrine) 
  • Topical for skin, Mentholatum, Vicks VapoRub (camphor, eucalyptus or menthol rubs)

Efficacy and risks: Nasal decongestants have a modest, but noticeable, effect. The sprays work within minutes, but can worsen stuffiness if taken for longer than three days. The pills can raise blood pressure, cause insomnia, heartbeat abnormalities, tremors, anxiety and hallucinations. The topicals improve the flow of air through your nasal passages, but can irritate the skin.

For These Symptoms: Cough

Home remedies: Honey—It tastes good and feels soothing, and one 2014 review suggests that it’s better than a placebo at easing coughs. Add a teaspoon or two  to a cup of hot tea or let a teaspoonful slide down and cool your throat. 

Caution: Honey should not be given to infants younger than a year old, because it can contain the bacterium Clostridium botulinum, dangerous constipation and weakness.

Medicines:

  • Robitussin Long-Acting CoughGels, Vicks DayQuil Cough (dextromethorphan)
  • Mucinex 12 Hour, Tab Tussin (guaifenesin)Halls Menthol Cough Drops, Mentholatum, Vicks VapoRub (topical rubs, patches and lozenges that contain camphor or menthol) 

Efficacy and risks: Mucinex works by breaking up mucus in your throat, so you can expel it more easily if you have a “wet” cough. Some other cough suppressants, like Robitussin, are antitussives, meaning they reduce your reflex to cough. Evidence on the efficacy of these medicines is limited and mixed. If used continuously, cough drops can cause a rebound effect, worsening your cough over time. Antitussives can lead to confusion, constipation, stomach pain and headache. Taking too much may be dangerous, causing you to become weak and dizzy and slow down your breathing. 

Caution: Cough suppressants can cause increased sedation when taken with narcotics, sleeping pills, antihistamines or alcohol.


For These Symptoms: Runny Nose and Sneezing

Medicines: Antihistamines, such as Zyrtec (cetirizine), Aller-Chlor (chlorpheniramine), Benadryl Allergy (diphenhydramine),  Allegra (fexofenadine)  and Alavert, Claritin (loratadine). 

Efficacy and risks: A Cochrane Review, a systematic review of 18 trials, found that antihistamines can help reduce cold symptoms, but the effect is only likely to last a day or two.

Antihistamines can increase your heart rate, lower your blood pressure and cause drowsiness and constipation.

Caution: Taking chlorpheniramine or diphenhydramine with opioids, sleeping pills or alcohol makes sedation more likely.


For These Symptoms: Sore throat

Home remedies: Gargle with salted water. It’s inexpensive, safe and time-tested. Dissolve ½ to 1 teaspoon of salt into an eight-ounce glass of warm water, gargle in the back of the throat, then spit it out. Repeat a few times a day.

Medicines:

  • Pain relievers such as acetaminophen, ibuprofen and naproxen
  • Cepacol Extra Strength Sore Throat Sugar Free, Chloraseptic Warming Sore Throat Lozenges (benzocaine) 
  • Sucrets Sore Throat Lozenges (dyclonine )
  • Halls Triple Action Soothing Drops, Vicks VapoDrops (methol)
  • Chloraseptic Sore Throat Spray (phenol)

Efficacy and risks: Pain relievers help. For the risks of pain relievers, see Body Aches and Fever above.

Benzocaine, dyclonine and phenol work as local anesthetics, and menthol provides a cooling sensation in your throat. If the sore throat is accompanied by fever, you should consider getting tested for strep throat. For the risks from pain relievers, see “Body Aches and Fever,” above.

In rare cases, exceptionally large doses (two bags a day for 20 years) of lozenges can cause headaches, dizziness, breathing problems, sweating or seizures.

Are Combination Drugs Safe?

Many cold and flu products take a scattershot approach. For example, Vicks NyQuil Severe Cold & Flu Relief contains acetaminophen to treat aches and fever, dextromethorphan for coughs, phenylephrine for congestion and doxylamine to help you sleep.

When you feel lousy all over, such products can be tempting to take. But, safety-wise, it’s better to stick to single-ingredient products as much as possible. Why? Because the more drugs included in a product, the greater the risk of side effects.

For example, sedating antihistamines such as diphenhydramine, found in many combos, make falls more likely for adults 65 and older, and especially people who may take other medications that cause drowsiness. And too much acetaminophen, which is included in more than 600 OTC products, can lead to serious liver damage.

If you do opt for a combo drug, stick to one that treats the symptoms you actually have. “It just doesn’t really make sense to expose your body to ingredients you don’t need,” says Leigh Ann Mike, a pharmacist at the University of Washington.

Also, compare prices of brand-name combo drugs, such as Nyquil and Theraflu, with store-brand versions. The latter may have the same ingredients and are almost always cheaper.

The Danger of Too Much Acetaminophen (Tylenol)

Acetaminophen is generally the safest pain and fever reducer on the market. But it has a big downside if used in high doses. Studies have shown excessive use is common for people with colds and the flu—people who (a) assume that this widely available and popular pill is totally safe and (b) may not be aware that acetaminophen is an ingredient in hundreds of different cold and flu symptom products. As shown in this table, it’s easy to consume more than is safe.

High doses of acetaminophen cause illness and liver damage in tens of thousands of patients each year.

 HOW MUCH ACETAMINOPHEN ARE YOU TAKING?

Product and Purpose Acetaminophen per pill Acceptable dose per day Total
Tylenol Extra Strength 500 mg 6 pills 3,000 mg
Theraflu Express Max
Daytime Severe Cold & Cough
325 mg 8 pills 2,600 mg
NyQuil Cold and Flu Nighttime Relief 325 mg 2 pills 650 mg
Total 6,250 mg

The maximum daily dose recommended by most medical authorities: 3,250 mg

The daily dose linked to liver damage (even after only a single day’s use): 4,000 mg

The daily dose considered potentially fatal (even after a single day’s use): 7,500 mg

Consumer Reports took a deep dive into that question for its January 2018 cover story. Here’s what you need to know, including warnings on overdoing it with excessive use of over-the-counter drugs, vitamins and supplements.

Do Supplements Relieve Symptoms or Shorten the Duration of a Cold or the fFu?

Some recent research suggests that certain vitamins and herbs can ease cold and flu symptoms or shorten their duration. Overall, the evidence backing up most supplements in treating colds or the flu, however, ranges from weak to nonexistent.

Unlike drugs, the FDA doesn’t require that supplements be proven safe and effective before they head to market. Here’s the rundown on a few popular remedies.

Echinacea

A Cochrane Review of 24 trials hinted that echinacea teas or supplements might help prevent colds, but the results were inconclusive. Echinacea can also trigger nausea and worsen asthma for some people. Any hot tea—with or without echinacea—can help soothe some cold and flu symptoms.

Vitamin C

Vitamin C is critical to immune function, and having too little of it can leave you susceptible to colds and flu. There’s no conclusive evidence that supplements can actually treat an infection once it’s taken hold. Further,  loading up with megadoses of vitamin C after symptoms appear doesn’t help at all. Vitamin C can raise the risk of kidney stones and interacts negatively with cancer drugs, blood thinners and estrogen.

Zinc

Zinc may reduce the length of a common cold by just over two days, according to a 2020 meta-analysis. A separate trial that examined  a commercially available zinc lozenge found that those who used the zinc actually took longer to recover than those given a placebo. Possible side effects include diarrhea, nausea, stomach cramps and vomiting. Long-term use, especially in high doses, may cause copper deficiency, which can trigger anemia. The supplement can also interfere with certain antibiotics, by lowering their efficacy.

Read the label

Nighttime. Non-Drowsy. Maximum Strength. When you see those terms on an over-the-counter drug label, you might assume they have a uniform meaning. Not true. The FDA has no set definition for these terms. That means drugmakers can improvise.

“These claims are basically advertising copy—meant to catch your eye,”

says Barbara Young of the American Society of Health-System Pharmacists.

For example, the terms non-drowsy or daytime suggest that a product doesn’t contain a sleep aid, as in the case of Contac Cold & Flu Day. But it can also mean that a product includes a stimulant, such as the pseudoephedrine in Advil Cold & Sinus Non-Drowsy. Some people react badly to pseudoephedrine; it amps them up. So, yes, non-drowsy, but not always in a good way.

Similarly, the terms `night,  nighttime or pm often indicate that a product contains an antihistamine with drowsiness as a side effect. But different brands use different sleep aids: Alka-Seltzer Plus Maximum Strength Night Cold & Flu relies on doxylamine and Tylenol PM opts for diphenhydramine. Again, you may react better or worse to one or the other.

The terms expressfast,“maximum, and extra strength can also be misleading  and vary from product to product. For example, Theraflu labels its products ExpressMax, except for its hot-drink powders.Mucinex adds Fast-Max to all its multi-symptom products, though nothing in the packaging explains how the products work faster.Robitussin Maximum Strength Cough & Chest Congestion DM has twice as much guaifenesin, an ingredient that may thin mucus, as the regular version—but both versions have the same amount of dextromethorphan.

Most important, higher doses of any ingredient aren’t always needed—and pose greater risk for little or no extra benefit.

Get Your Flu Shot!

The CDC estimated that the 2019-2020 flu vaccine prevented 6,300 flu-associated deaths along with more than 100,000 hospitalizations and 3.7 million infections. In 2017 and 2018, only about 37% of adults in the US got their flu vaccine. During the following year, coverage increased to about 45% of adults. Between 2019 and 2020, which was during the pandemic, more than 50% of adults received a flu vaccine. This year, you can get your COVID-19 shots at the same time as your flu vaccine.

Many people avoid flu shots and have lots of reasons not to get them. Here are  two common excuses to avoid the flu shot and rebuttals:

Myth #1: Flu Shots Don’t Work

In a typical year, the flu shot cuts your risk of getting the flu by 40% to 60%. If you get the flu anyway, your symptoms will be milder, and “You’re less likely to have complications, less likely to be admitted to the hospital and less likely to die,” says William Schaffner, MD, medical director of the National Foundation for Infectious Diseases.

Myth #2: It Can Cause the Flu

Almost all flu vaccines use an inactivated virus that does  NOT trigger the flu. But because the vaccine doesn’t eliminate your chance of getting the flu, and only reduces it, some people who develop the flu after getting the shot wrongly blame the vaccine.

Which vaccine should you get? Most years, teens and adults should consider a quadrivalent vaccine, which protects against four flu strains. People 50 and older have another option: Flublok Quadrivalent, which has triple the dose of other quadrivalents. Those 65 and older have two more choices: Fluzone High-Dose and Fluad. Both protect against only three strains, but Fluzone has four times the dose and Fluad adds an ingredient to boost the immune system’s response.Which vaccine should you have?

Most years, teens and adults should consider a quadrivalent vaccine, which protects against 4 flu strains.

People 50 and older have another option: Flublok Quadrivalent, which has triple the dose of other quadrivalents.

Those 65 and older have 2 more choices: Fluzone High-Dose and Fluad. Both protect against only 3 strains, but Fluzone has 4 times the dose and Fluad adds an ingredient to boost the immune system’s response.

If You Get the Flu, Should You Take Tamiflu or Other Antiviral Drugs?

Four antiviral drugs are FDA-approved to treat the flu: Tamiflu (oseltamivir), Relenza (zanamivir), Rapivab (peramivir) and Xofluza (baloxavir marboxil) .

They help the most when you take them within 48-hours of symptoms first appearing, but may help for up to four to five days after you first feel sick. They may also reduce the risk of complications (such as pneumonia and bronchitis, or even death). (See, Need to Know: Tamiflu.)

Experts and doctors differ on when to prescribe these medicines. Most doctors only prescribe them for people who have other illnesses or are at high risk for complications from the flu or both. That includes people over 65 and pregnant women. One reason doctors may not prescribe them to younger, healthier people is because of the side effects. The drugs can cause nausea, vomiting, headache and delirium.


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