eMedicine Specialties > Infectious Diseases > Viral Infections
Rhinoviruses: Treatment & Medication
Updated: Jun 30, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Rhinoviral infections are predominately mild and self-limited; thus, treatment is generally focused on symptomatic relief and prevention of person-to-person spread and complications. The mainstays of therapy include rest, hydration, antihistamines, and nasal decongestants.
Antibacterial agents are not effective unless bacterial superinfection occurs. Development of effective antiviral medications has been hampered by the short course of these infections. Because peak symptom severity occurs at 24-36 hours after inoculation, antivirals have only a narrow window to positively affect a rhinoviral infection. In addition, the cause of the common cold is not always rhinoviral infection. Therefore, rapid and accurate diagnostic tests would be needed if a specific antiviral therapy were developed.
- Because of the large number of rhinovirus immunotypes and the inaccessibility of the conserved region of the viral capsid (the most likely effective site for targeting a vaccine), no rhinovirus vaccine is on the horizon.
- Because infection is spread by hand-to-hand contact, autoinoculation, and, possibly, aerosol particles, emphasize appropriate hand washing, avoidance of finger-to-eyes or finger-to-nose contact, and use of nasal tissue.
- Heated humidified air has been used for decades for the alleviation of symptoms due to rhinoviral infections but has never been shown to improve objective outcome measures.34
- Numerous agents are under investigation for the treatment of viral infections.
- Pleconaril inhibits approximately 92% of rhinovirus serotypes. Susceptibility to pleconaril depends on the viral capsid surface protein VP1. A double-blind, randomized, placebo-controlled trial of pleconaril 400 mg PO tid for 5 days, initiated within 24 hours of symptom onset, resulted in a decrease in the duration of symptoms by 1 day.14
- Steroids have been examined as a therapeutic modality and have shown little effect with rhinoviruses. One recent article noted that children who experienced wheezing during a rhinoviral infection and were treated with prednisolone experienced fewer wheezing episodes than untreated individuals in the subsequent 2 months. However, no change in time to discharge was noted.18
- A blinded, placebo-controlled trial using intranasal interferon-alpha-2b and ipratropium with oral naproxen started within 24 hours of rhinovirus inoculation decreased viral shedding, geometric mean virus titers, and symptoms in the treatment group. Similar findings were reported with the use of intranasal interferon-alpha-2b, chlorpheniramine, and ibuprofen. Recombinant interferon-alpha-2b applied topically to the nose at 5 million U or more per day prevented experimental infections. Unfortunately, the effect of this agent on symptomatic illness was limited.11
- A recombinant soluble intercellular adhesion molecule-1 (ICAM-1) administered intranasally 6 times per day and beginning either 7 hours before or 12 hours after rhinovirus challenge was analyzed in a randomized, double-blinded study. Neither strategy affected the incidence of infection, but combining results from both treatment groups found a 23% decrease in clinical colds, a 45% decrease in total symptom score, and a 56% decrease in total nasal secretion weight.50
- 3C protease inhibitors are currently being evaluated in human trials, but no data are currently available. A phase II study found that ruprintrivir, a 3C protease inhibitor, delivered as a nasal spray was well tolerated and decreased positive viral culture results and improved symptom scores but did not decrease the frequency of colds.15 These drugs act by interfering with the cleaving of a single large polyprotein that produces individual structures and enzymatic proteins of the virus.
- Rhinoviruses are sensitive to low pH. In one recent study, citrate/phosphate buffers were administered intranasally, decreasing viral shedding but failing to decrease symptomatology.48
Diet
Dietary supplements have been touted as possible therapeutic or preventive measures.
- Although large doses of vitamin C have been used for prevention and treatment of colds, controlled trials reveal minimal therapeutic benefit and no preventive qualities.33
- Zinc has been found to inhibit rhinovirus replication in vitro, but no proven benefit has been shown in vivo on virus activity or immune modulation.
- The genus Echinacea consists of 3 species of plants used medicinally for their reported nonspecific stimulation of the immune system.
- Echinacea purpurea has recently been studied and did not show any differences in rates of infection or severity of illness when compared with placebo. Although reports of improved symptoms have been described, validation and standardization of products is necessary.36
- Echinacea angustifolia has also been examined in the prophylaxis and treatment of experimental rhinoviral infection. Neither the rate of infection nor the severity of symptoms were found to be statistically significantly affected when E angustifolia was used either prophylactically or at the time of challenge.39
- In contrast, a recent meta-analysis of echinacea indicated that, in properly designed studies, patients receiving placebo were 55% more likely to experience cold symptoms than patients taking echinacea. The most striking part of this meta-analysis was that 231 of 234 articles identified were excluded because they did not control for the type of viruses causing the colds. Echinacea extracts will continue to be evaluated.32
Activity
Patients may limit their activity during the course of the infection, with clinical improvement occurring 48-72 hours after the prodrome of symptoms.
Medication
Drugs used in the symptomatic treatment include nonsteroidal anti-inflammatory drugs (NSAIDs), antihistamines, and anticholinergic nasal solutions. These agents have no preventive activity and appear to have no impact on complications. The combined effect of NSAIDs and antihistamines often relieves nasal obstruction; therefore, decongestion therapy is rarely needed. Oral (pseudoephedrine) and topical (oxymetazoline and phenylephrine) decongestants are commonly used for symptomatic relief.
First-generation antihistamines reduce rhinorrhea by 25-35%, as do topical anticholinergics and ipratropium bromide. Second-generation or nonsedating antihistamines appear to have no effect on common cold symptoms. Corticosteroids may actually increase viral replication and have no impact on cold symptoms.
Antihistamines
These agents act by competitive inhibition of histamine at the H1 receptor.
Diphenhydramine (Benylin, Benadryl)
Occasional drowsiness and is suitable for use on a day-to-day basis. Oral H1-blocker used in the treatment of allergic conjunctivitis and rhinitis, angioedema, pruritus, and urticaria.
Adult
25-50 mg PO q6-8h prn; not to exceed 400 mg/d
10-50 mg IV/IM q6-8h prn; not to exceed 400 mg/d
Pediatric
12.5-25 mg PO tid/qid, or 5 mg/kg/d, or 150 mg/m2/d divided tid/qid; not to exceed 300 mg/d
5 mg/kg/d IV/IM or 150 mg/m2/d, divided qid; not to exceed 300 mg/d
Potentiates effect of CNS depressants; because of alcohol content, do not administer syrup dosage form to patients taking medications that can cause disulfiram-like reactions
Documented hypersensitivity; MAOIs
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, or urinary tract obstruction; xerostomia may occur
Chlorpheniramine (Telachlor, Chlo-Amine, Chlor-Trimeton, Aller-Chlor)
Competes with histamine or H1-receptor sites on effector cells in blood vessels and respiratory tract.
Adult
10-20 mg IV/IM/SC once; not to exceed 40 mg/d
4 mg PO q4-6h; not to exceed 24 mg/d or 8-12 mg SR q8-12h; not to exceed 24 mg/d
Pediatric
<2 years: Not established
2-6 years: 1 mg PO divided q4-6h; not to exceed 6 mg/d
6-12 years: 2 mg PO q4-6h; not to exceed 12 mg/d or 8 mg SR PO hs
>12 years: Administer as in adults
CNS toxicity increases with coadministration of other CNS depressants, tricyclic antidepressants, MAOIs, and phenothiazines
Documented hypersensitivity; asthma attacks; narrow-angle glaucoma; symptomatic prostate hypertrophy; bladder-neck obstruction; stenosing peptic ulcer
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause significant confusional symptoms; not for administration to premature or full-term neonates
Brompheniramine maleate (Bromphen, Nasahist B, Dimetane Extentabs)
Does not tend to cause drowsiness and is suitable for use on a day-to-day basis. Oral H1-blocker used in the treatment of allergic conjunctivitis and rhinitis, angioedema, pruritus, and urticaria.
Adult
Capsule/elixir: 4-8 mg PO q6-8h prn
Extended-release form: 8 mg PO q8-12h or 12 mg PO q12h prn; not to exceed 24 mg/d
Pediatric
<2 years: Not established
2-5 years: 1 mg PO q4-6h prn; not to exceed 6 mg/d
6-11 years: 2-4 mg PO q6-8h prn; not to exceed 12 mg/d
>12 years: Administer as in adults
MAOIs and beta-blockers increase the effects of sympathomimetics; may reduce antihypertensive effects of methyldopa, mecamylamine, reserpine, veratrum alkaloids; alcohol and other CNS depressants may have an addictive effect
Documented hypersensitivity; severe hypertension; severe coronary artery disease; current or within 14 days of MAOI use; narrow-angle glaucoma; urinary retention; peptic ulcer disease; during an asthma attack
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with hypertension, heart disease, diabetes, or thyroid disease; antihistamines may cause drowsiness
Anticholinergics
These agents have antisecretory properties and, when applied locally, inhibit secretions from serous and seromucous glands lining the nasal mucosa.
Ipratropium intranasal (Atrovent)
Two strengths of nasal spray: 0.03% for treatment of rhinorrhea associated with allergic and nonallergic perennial rhinitis and 0.06% for treatment of rhinorrhea associated with common cold. Chemically related to atropine.
Adult
Rhinorrhea common cold 0.06% nasal solution: 2 sprays (42 mcg/spray) per nostril tid/qid
Rhinorrhea allergic/nonallergic perennial rhinitis 0.03% nasal solution: 2 sprays (21 mcg/spray) per nostril bid/tid
Pediatric
Administer as in adults
Drugs with anticholinergic properties, such as dronabinol, may increase toxicity; albuterol may increase effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients with narrow-angle glaucoma, prostatic hypertrophy, or bladder-neck obstruction
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These agents have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known but may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms also may exist (eg, inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, various cell membrane functions).
Naproxen (Anaprox)
For relief of mild to moderate pain and antipyretic action; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
550 mg PO q12h or 275 mg PO q6-8h prn
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Ibuprofen (Ibuprin, Motrin)
For relief of mild to moderate pain and antipyretic action; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
More on Rhinoviruses |
| Overview: Rhinoviruses |
| Differential Diagnoses & Workup: Rhinoviruses |
 Treatment & Medication: Rhinoviruses |
| Follow-up: Rhinoviruses |
| References |
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Further Reading
Keywords
rhinoviruses, rhinovirus infection, cold, common cold, respiratory virus, RV, acute respiratory tract infection, ARTI, upper respiratory tract infection, URTI, otitis media, sinusitis, chronic bronchitis, lower respiratory tract illness, rhinoviral infection, rhinorrhea
