Feeling sick? Here’s how different cold and flu drugs work

With early surges of flu, RSV, and other seasonal respiratory illnesses that are piling on recent increased COVID cases, it has been a rough winter already—not just because of all the coughs and fevers, but because it can be hard to find the medications commonly used to treat those symptoms. The FDA is listing more than 100 current and recently resolved drug shortages, with others reported locally, including amoxicillin, Children’s Tylenol, and Tamiflu.

“We're getting more callbacks from pharmacies because they don't have the prescription that we've written,” says Erin Fox, senior pharmacy director at the University of Utah Health in Salt Lake City. “I’m hearing from a lot of fellow physicians across the country that they are experiencing the same thing.”

The reasons for the shortages are a complex combination of supply chain issues, surging demand, and a hoarding effect that happens when people know supplies are low, experts say. Adding to the problem are persistent myths and misconceptions about which medications are needed, when, and for which people.

“Shortages are a time when we try and kind of triage these medications to the people who will benefit the most from taking them,” says Nipunie Rajapakse, a pediatric infectious disease physician at the Mayo Clinic in Rochester, Minn.

As the infection-laden winter drags on, experts say that better understanding the role that medications play in treating various illnesses could relieve anxiety about empty pharmacy shelves, reduce the harms of unnecessary medication use, and improve supply for people most in need.

Tamiflu

Reports of influenza started to spike in October 2022. By early December, the United States was experiencing one of its earliest and most severe flu seasons in years. As cases surged, so did demand for Tamiflu, also called oseltamivir. The antiviral, according to the CDC, is recommended most for people at high risk from developing severe cases of influenza—a broad category that includes kids under two, adults 65 and up, pregnant and immunocompromised people, and those with asthma, kidney disease, or other underlying conditions.

But anyone can get a prescription for it. And as the flu raged, the medication became difficult to come by in a variety of places. Some pharmacies struggled to keep Tamiflu in stock, and people reported calling multiple stores to get prescriptions filled as the clock ticked: Tamiflu is most effective if started as soon as possible and within 48 hours of the onset of symptoms.

Despite that sense of urgency, Tamiflu is unlikely to be the miracle cure that people may expect. In a comprehensive review of 20 studies encompassing more than 24,000 people, researchers with the independent Cochrane Collaboration reported in 2014 that the drug reduced the duration of symptoms in adults by an average of 16 hours—which meant that people were sick for about six days instead of seven.

The drug didn’t make any significant dent in symptom duration for kids. Nor did it reduce the risk of hospitalization or other complications, like pneumonia, bronchitis, or ear infections. But there were side effects, some serious. The drug increased the risk of nausea and vomiting by 4 percent in adults and 5 percent in kids. In some cases, Tamiflu caused psychiatric symptoms, such as depression, delusions, and panic attacks.

Even among those in high-priority groups, data are still not clear on how much of a difference the drug makes, Fox says. “It’s definitely not a cure-all,” she says, and not being able to get it is often not the end of the world. “It doesn't mean that you're going to end up in the hospital. It probably is going to mean that you're not going to have that opportunity to get better half a day earlier.”

Acetaminophen and ibuprofen

Fevers can seem scary, particularly in little kids and especially when numbers start creeping well above triple digits. But misconceptions go both ways about how and when a fever needs to be treated with medication.

One myth is that treatment is necessary to reduce the risk of complications like seizures in children—a belief that is not supported by the bulk of evidence, says Rajapakse. Febrile seizures are triggered by a rapid rise in temperature rather than the high temperature itself, she says, so by the time the fever spikes, it’s too late for the medication to make a difference. Some studies show potential prophylactic benefit, she says, but most suggest that giving acetaminophen or ibuprofen around the clock “does not necessarily prevent a febrile seizure if it's going to happen.”

On the flip side is the belief that acetaminophen impairs the body’s own immune-strengthening response to treat a fever. But experts say these medications are not powerful enough to shut down your immune system and people shouldn’t try to fight off a fever without relief if they’re feeling awful.

If a fever reaches 105, it’s time to go to the emergency room, says Megan Ranney, an emergency physician at the Brown University School of Public Health in Providence, Rhode Island, who adds that aspirin is not safe for kids.

Below emergency levels, Rajapakse recommends treating for comfort. She often sees toddlers in the clinic with 103 degrees fever who are running around and feeling great, and she doesn’t recommend medication in those cases. “Then you can see a child who has a lower fever but who is pretty miserable, who might not be eating and drinking much, who's waking up a lot at night, who's uncomfortable,” she says. “That's a very reasonable scenario to treat a fever in that child.”

Antibiotics

Amoxicillin is a go-to workhorse in pediatrics that is used to fight bacterial ear infections, pneumonia, and strep throat, with relatively few side effects, says Rajapakse. But a shortage of amoxicillin has forced doctors to prescribe other antibiotics that may be harder to tolerate or might not work as well against the bacteria causing infections.

The shortage highlights ongoing issues with excessive antibiotic prescriptions. About a third of antibiotics prescribed to people of all ages are either totally unnecessary or prescribed incorrectly, studies show—which includes using the wrong drug, dose, or duration of treatment. The shortage began just as the U.S. Centers for Disease Control and Prevention and the World Health Organization were finishing up a week of meetings dedicated to reducing overuse of antibiotics.

“It’s a continual challenge,” Ranney says. “Every time we start to make a little progress, we fall backwards again.”

Unnecessary antibiotic use not only raises the risk for allergic reactions, kidney problems, and side effects like diarrhea in people who take them, Rajapakse says. The practice also gives bacteria opportunities to develop drug resistance, which is harmful to society.

One reason the problem persists is that people mistakenly believe they need antibiotics for things like ear infections or ongoing coughs, even when viruses are likely to blame. “I can't tell you how many patients show up in the ER saying, ‘I’ve had this cough for two weeks. I know that I just need an antibiotic,’” Ranney says. “We know that if we don't prescribe it, they're going to go to someone else who will.”

Given how busy providers are, Rajapakse says, it can be quicker for them to prescribe something than to take the time to explain why people might not need medication. It can also be tricky to get it right and tempting to err on the side of caution. About 90 percent of sore throats are caused by viruses, for example, but 10 percent are a sign of strep throat, which needs antibiotic treatment to prevent future complications.

To reduce unnecessary antibiotic use, Rajapakse advises parents to ask providers if their child is a candidate for watchful waiting instead of demanding or immediately accepting a prescription, and focusing on other ways to alleviate symptoms, including acetaminophen or ibuprofen, popsicles, humidifiers, and nasal saline. “There are lots of things that families can do that don't involve taking an antibiotic while their child's immune system fights off the virus,” she says.

Even when this flu season ends, drug shortages are likely to remain an ongoing issue, researchers say, as they have been a problem for years. In 2018, well before COVID struck, the FDA pulled together a task force that identified several causes of the drug-shortage crisis, including a lack of incentive for drug companies to produce less profitable drugs and logistical challenges that impede the market’s ability to recover after disruptions. Although the group’s report also suggested solutions, such as financial incentives to produce lower-cost drugs and transparency about when shortages are happening, the problems persist.

Preparation can help people weather the ups and downs. Experts recommend keeping a small supply of over-the-counter medications (no hoarding!) on hand in case you get sick. Boost your arsenal of non-drug strategies for feeling better, like lukewarm baths or tea with honey. Understand your family’s particular risk level so you know if you’ll want to seek a diagnosis as soon as you feel ill and be prescribed antivirals quickly if you need them.

It’s always a good idea to practice good health habits, Ranney adds. “Get your flu shot. Get your booster for COVID. Make sure you wash your hands and wear masks, particularly in crowded indoor locations,” she says. “The best way to avoid needing medications is to avoid getting sick in the first place.”