Community pharmacists are often the first healthcare professionals consulted when a patient develops a head cold. The request may be simple: ‘What can I take for this?’ Yet many products offer only short-term relief, some are unsuitable for particular patients, and antibiotics have no role in uncomplicated viral infections.
Recent evidence suggests that isotonic saline nasal spray deserves a more prominent place in this conversation. Saline is inexpensive, available over the counter and is well tolerated. A large primary-care trial found that advice to use it early and regularly was associated with fewer respiratory illness days, less disruption to work or normal activity, and lower self-reported antibiotic use.
Community pharmacy is well placed to translate that evidence into practical self-care.
After reading this article, pharmacists will be able to:
Nasal saline has been used for coryzal, rhinitis and sinus symptoms for many years. A 2015 Cochrane review found possible benefit in acute upper respiratory tract infections, but confidence was limited because the studies were small and at risk of bias.
The evidence base changed with the Immune Defence trial. This pragmatic, open-label study recruited 13,799 adults through 332 UK general practices. Participants had recurrent respiratory infections, a relevant comorbidity or another factor associated with increased risk from respiratory illness. They were allocated to usual care, a gel-based nasal spray, an isotonic saline spray or a behavioural intervention.
At six months, participants advised to use isotonic saline had about one-fifth fewer respiratory illness days than those receiving usual care. Self-reported antibiotic use was approximately 30 per cent lower, and days lost from work or normal activities were also reduced.
These outcomes matter at the pharmacy counter. The potential benefit is not simply that the nose feels less blocked, but that the patient may spend fewer days feeling unwell and experience less disruption to everyday life.
At 12 months, both nasal spray groups averaged approximately 18 respiratory illness days over the year, compared with 22 days with usual care. The saline group also reported fewer respiratory-related GP consultations. Antibiotic courses were lower at six months. The 12-month estimate also appeared lower but was just at the margin of statistical significance. Benefits appeared particularly marked among people with recurrent respiratory infections.
The evidence should still be interpreted carefully. The trial was open-label, the population was enriched for recurrent or higher-risk respiratory illness, and adherence to preventive use after exposure was limited. These limitations should temper the claims, but the study was large, pragmatic and conducted in the setting where most respiratory infections are managed.
The nasal mucosa is an early site of replication for many respiratory viruses. Saline may loosen secretions, support mucus clearance and reduce the local burden of viral particles and inflammatory material.
Laboratory work also suggests that chloride ions can augment antiviral activity in epithelial cells through increased intracellular production of hypochlorous acid, a molecule involved in innate antimicrobial defence. This is a plausible mechanism rather than a proven explanation for the clinical effect.
For patients, the message can remain simple: ‘The infection often starts in the nose. Saline may help clear the nasal lining and support its natural defences, particularly when started early.’
Patients may use the term ‘nasal spray’ to describe very different products. Isotonic saline is a saltwater preparation and should be distinguished from topical sympathomimetic decongestants such as xylometazoline or oxymetazoline.
Topical decongestants can provide short-term relief, but prolonged or excessive use can cause rebound congestion and drug-induced rhinitis. Systemic decongestants containing pseudoephedrine may cause insomnia, nervousness, dry mouth, palpitations, hypertension or difficulty passing urine. They also have important contraindications and interactions.
These medicines still have a place for selected patients when used correctly. However, isotonic saline is an attractive first option for early coryzal symptoms because it avoids sympathomimetic effects and can be used regularly according to the individual product instructions.
Acute sinusitis requires a separate distinction. Current HSE guidance advises self-care for all patients and notes that saline preparations may be tried for local irrigation. For adults with symptoms persisting without improvement for approximately 10 days or more, high-dose intranasal corticosteroids may be considered. Saline should therefore complement, rather than replace, appropriate assessment and current sinusitis guidance.
A request for a cold remedy is an opportunity to assess, explain and empower. The CHESTSSS consultation model, developed for respiratory infection consultations, can be adapted readily to community pharmacy.
Begin with the patient’s Concerns. Are they worried about pneumonia, sinusitis, fever, missing work or infecting a vulnerable relative?
Take a focused History, including symptom duration and severity, relevant comorbidities, pregnancy, medicines already used and warning features.
Ask about Expectations. Is the patient looking for rapid decongestion, pain relief, reassurance, an antibiotic or advice about recovery?
Explain the Symptoms. Coloured nasal mucus does not by itself indicate bacterial infection, and cough and nasal symptoms often last longer than patients expect. Regarding Timelines, it is common for sore throats to last for up to one week; the common cold can take up to two weeks; acute sinusitis can take up to three weeks to resolve and cough symptoms due to an acute viral illness can also take up to three weeks to resolve.
Discuss the Shortcomings of antibiotics for uncomplicated viral illness. Then offer practical Self-care, including saline and suitable pain relief, followed by clear Safety-netting.
A concise explanation might be:
“This sounds consistent with an uncomplicated head cold. Antibiotics do not usually help this type of infection. An isotonic saline spray is an option that may reduce symptoms and the time you feel unwell if you start early and use it regularly. Let me show you how to use it properly, and I will explain when you should seek further medical advice.”
The HSE’s Treat Your Respiratory Tract Infection leaflet sets out expected timelines, self-care, shortcomings of antibiotics and safety-netting advice in writing. A similar leaflet tailored for use by pharmacists is under development.
In the Immune Defence trial, the treatment regimen was two sprays into each nostril up to six times daily, beginning at the first sign of illness. Participants were advised to use the first dose on waking, another dose approximately one hour later, and to space the remaining four doses through the day. The accompanying patient materials advised continuing until two days after symptoms had resolved.
This was a study regimen rather than a universal licensed dosage for every product. Pharmacists should check the instructions for the individual spray and consider the patient’s age and circumstances.
Poor technique can send most of the liquid directly into the throat rather than distributing it across the nasal lining. A brief demonstration may add more value than simply handing over the product.
Advise the patient to:
A useful memory aid is: Aim out, spray, gentle sniff.
A slight taste is not harmful, but if most of the spray runs into the throat, the patient should keep the head straighter, aim further outwards and sniff less vigorously.
Side effects are generally minor and may include transient stinging, a tickle, dryness or an unpleasant taste. If use becomes uncomfortable, the patient can reduce the frequency, pause or stop. Each bottle should be used by one person to reduce the risk of cross-contamination.
Paracetamol may help fever, headache, sore throat or general aches when suitable for the patient. Pharmacists should check for duplicate paracetamol or ibuprofen in combination cold and flu products and advise age-appropriate dosing. Tailored written advice can be very helpful
Whilst there is no good evidence that increasing fluid intake improves respiratory infection outcomes, warm drinks may be comforting.
Most uncomplicated upper respiratory infections can be managed with self-care. Medical assessment is appropriate when the patient:
A lower threshold for medical assessment is appropriate in pregnancy, adults aged 65 years or older, people who are immunocompromised, and those with diabetes, significant heart, lung or kidney disease. Emergency referral pathways apply where symptoms are severe.
Community pharmacy can make nasal saline advice visible and consistent. Practical steps might include:
The value lies not only in the product, but in helping the patient understand what is happening, what they can do, how long recovery may take and when to seek help. This supports antimicrobial stewardship without making the consultation feel like a refusal of treatment.
When patients receive an active and credible self-care plan, they may be more confident managing uncomplicated illness at home and less likely to seek antibiotics or reconsult unnecessarily.
The message for pharmacy practice is straightforward: recommend isotonic saline early, explain how to use it correctly, distinguish it from decongestants and always safety-net.
For the common cold, a useful solution may have been under our noses all along!
Scott Walkin
GP, and Clinical Lead for Antimicrobial Resistance and Infection Control at the Irish College of GPs
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