You\u2019ve got the sniffles and your nose is running like a tap. The tissues feel like sandpaper. <\/p>\n
Many Australians reach for cold and flu tablets, expecting them to \u201cclear the sinuses\u201d and get them through a cold. They often promise fast relief.<\/p>\n
But the evidence is clear: for nasal congestion, these medicines do not work as well as they claim. So why are they still being sold? <\/p>\n
What\u2019s actually in cold and flu tablets?<\/p>\n
Most over-the-counter<\/a> cold and flu tablets contain a mix of ingredients. Some packs contain different tablets for day and night.<\/p>\n \u201cDay\u201d products often include<\/a> paracetamol or ibuprofen to ease aches and pains, along with a decongestant for a runny or blocked nose. \u201cNight\u201d products typically have an extra ingredient \u2013 an antihistamine to make you drowsy and help with sleep.<\/p>\n In Australia, the most common<\/a> oral decongestant used in these products is phenylephrine. It works by narrowing blood vessels in the nose, reducing swelling and making it easier to breathe. <\/p>\n You can also buy phenylephrine as a nose spray, although it\u2019s less common. If you spray phenylephrine into your nose it works well as a decongestant. But a large body of research has established it has almost no effect when swallowed in a tablet. <\/p>\n So, why is phenylephrine still widely sold?<\/p>\n Some important context<\/p>\n In the early 2000s, the main decongestant in cold and flu tablets was pseudoephedrine. Phenylephrine was rare as an oral medicine, though it had been available as a nose spray<\/a> since the 1990s.<\/p>\n But between 1996 and 2005 there was a significant spike<\/a> in illicit drug manufacture in Australia.<\/p>\n Pseudoephedrine<\/a> \u2013 available over the counter \u2013 was one of the chemicals being used to make amphetamines including \u201cice\u201d and \u201cspeed\u201d. So pharmacies were increasingly targeted in break-ins, ram raids and armed hold-ups<\/a>.<\/p>\n This led<\/a> to tightened restrictions<\/a> on the sale of pseudoephedrine products, including their reclassification<\/a> in 2006 as \u201cpharmacist only\u201d. This meant<\/a> they could be bought without a prescription, but \u201cbehind the counter\u201d \u2013 a pharmacist had to be involved in the sale.<\/p>\n Pseudoephedrine became much harder to obtain, whether the intention was to use it legitimately, or not.<\/p>\n Phenylephrine replaced pseudoephedrine as the main decongestant in oral products, not because it was a better medicine but because there was less risk of it being misused. <\/p>\n Early studies and reviews suggested<\/a> phenylephrine was an effective alternative.<\/p>\n But the evidence has changed<\/p>\n Over time, better research has begun to tell a different story, particularly about phenylephrine taken orally.<\/p>\n Recent studies<\/a> have shown oral phenylephrine performs no better than a placebo for relieving nasal congestion.<\/p>\n Overall evidence<\/a> on oral phenylephrine is now consistent<\/a>: it does not meaningfully relieve nasal congestion when taken by mouth. <\/p>\n This is because, when take orally, only a very small amount of phenylephrine can get into the bloodstream and reach the nose<\/a>. <\/p>\n In contrast, a nasal spray delivers the drug directly to the nasal passages, where it can act on the blood vessels. <\/p>\n Why are these medicines still on shelves?<\/p>\n In 2023, an independent advisory committee to the US Food and Drug Administration (FDA) reviewed the evidence and concluded<\/a> oral phenylephrine is not effective for nasal congestion when given at standard doses. <\/p>\n In November 2024, the FDA proposed removing<\/a> oral phenylephrine from over-the-counter cold and flu tablets<\/a>.<\/p>\n In Australia, the Therapeutic Goods Administration<\/a> (TGA) is responsible for regulating these medicines.<\/p>\n A spokesperson for the TGA told The Conversation the regulator is aware of the FDA\u2019s proposal to remove oral phenylephrine from over-the-counter sale, \u201cbased on efficacy concerns not safety concerns\u201d.<\/p>\n The spokesperson said: \u201cAt this time, while the TGA does not have current plans to conduct a review of the effectiveness of oral phenylephrine, we will continue to monitor the outcomes of the FDA review and consultation.\u201d<\/p>\n The FDA has not yet announced the outcome of the proposal.<\/p>\n So, are cold and flu tablets safe?<\/p>\n While the evidence supporting oral phenylephrine as an effective decongestant has changed, the main concern is not that it causes harm. It\u2019s that consumers will pay more for a medicine that provides little relief for nasal congestion.<\/p>\n If people do feel better after taking cold and flu tablets, it\u2019s likely because of other ingredients, such as ibuprofen or paracetamol.<\/p>\n In Australia, products containing phenylephrine must be clearly labelled, allowing consumers to make an informed choice<\/a>. <\/p>\n What actually helps when you have a cold or flu?<\/p>\n For nasal congestion, short-term use of a decongestant nasal spray containing phenylephrine, oxymetazoline or xylometazoline can provide relief<\/a>. This means using them for a maximum of three days. <\/p>\n Using them for longer can cause<\/a> your symptoms to worsen or come back worse when you stop using it \u2013 this is called rebound congestion.<\/p>\n Saline nasal sprays or rinses also help to clear nasal congestion safely and effectively<\/a>, by physically dislodging phlegm, without the risk of rebound congestion.<\/p>\n For other options, speak to your pharmacist. In some cases, a GP or pharmacist may recommend products that contain pseudoephedrine. You may need to show identification<\/a> to the pharmacist, depending on the state or territory.<\/p>\n