FAQ: OTC Guidance for Respiratory Virus Season

Heading into the 2026 respiratory virus season, pharmacists have historically been tasked with matching the right product with the right symptom for the right patient, rather than letting marketing and multi-ingredient packaging drive the choice.

According to Mark Garofoli, PharmD, MBA, BCGP, CPE, CTTS, clinical assistant professor and director of experiential learning at West Virginia University School of Pharmacy, the biggest mistake patients make is reaching for the over-the-counter (OTC) product with the most ingredients instead of the one that treats the symptoms they actually have. Many combination cold and flu products contain unnecessary medications, raising the risk of adverse effects, drug interactions, and duplicate therapy.

“Treat the patient, not the packaging,” Garofoli told Drug Topics®, recommending that pharmacists ask every patient, every time, about 3 things: symptoms, current medications, and medical conditions.

As the greater pharmacy workforce, and health care as a whole, heads into the 2026 respiratory virus season, pharmacists may face unprecedented patient concerns and questions regarding the safest and most effective OTC options. With an elevated expertise on medications that fly off the shelves during the winter months, pharmacists should be primed for yet another cold and flu season.

Read through Garofoli’s insights and learn about some of the most effective approaches to protecting patients in the community as infectious disease rates get ready to rise.

READ MORE: FDA’s Stance on OTC Drugs Raises Complex Patient Safety Questions

What OTC products should pharmacists and patients be paying the most attention to heading into the 2026 respiratory virus season?

We pharmacists and our patients need to remember that the OTC aisle is not a one-size-fits-all buffet of medications. Between COVID-19, influenza, respiratory syncytial virus (RSV), and the common cold, the goal is to match the right product with the right symptom for the right patient while avoiding unnecessary medications, duplicative ingredients, and preventable adverse effects.

My biggest areas of focus are acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) for fever and body aches, decongestants for nasal congestion, cough suppressants and expectorants for respiratory symptoms, and combination cold and flu products that often contain more ingredients than patients need.

One product I would particularly highlight this season is oral phenylephrine. The FDA has proposed removing it as an OTC nasal decongestant because the available evidence does not support its effectiveness at recommended doses. Yet, it can still be found in many cold and flu products. Concurrently, patients should know that pseudoephedrine and certain nasal decongestant sprays are alternative options, although individual cardiovascular risks and other contraindications must be considered.

I would also encourage pharmacists to pay special attention to older adults, children, pregnant patients, and individuals with chronic medical conditions. A seemingly harmless OTC product can become problematic in someone with hypertension, kidney disease, cardiovascular disease, or polypharmacy. For children, age-appropriate dosing and avoiding inappropriate combination cough-and-cold products are especially important.

Finally, let's not forget that the most important respiratory virus products may be those that help prevent illness in the first place. Pharmacists should use every OTC consultation as an opportunity to discuss appropriate influenza, COVID-19, and RSV immunizations.

With so many combination cold and flu products on the shelf, what are the most common mistakes patients make when choosing and how can pharmacists help them pick the right one?

Treat the patient, not the packaging. The best OTC product isn't necessarily the one with the most ingredients or the flashiest marketing. It's the one that addresses the patient's actual symptoms while minimizing unnecessary risks.

The biggest mistake patients make is choosing the product with the most ingredients rather than the one that treats their minimal symptoms. Many combination cold and flu products contain unnecessary medications, increasing the risk of adverse effects, drug interactions, and duplicate therapy, particularly with acetaminophen.

Pharmacists can help by asking every patient, every time about 3 simple concepts: symptoms, current medications, and medical conditions. This leads us pharmacists to be able to confidently and accurately recommend targeted, single-ingredient products whenever possible, identify potential safety concerns, and provide appropriate dosing guidance.

How should pharmacists counsel patients on the effectiveness of OTC decongestants and expectorants, especially for patients that don’t believe the products they’re using are working?

When patients tell me their OTC decongestant or expectorant isn't working, my first question is, "Are we using the right medication for the right symptom?" Oral pseudoephedrine and short-term topical nasal decongestants may provide relief when appropriate for the patient despite the cumbersome process of attaining it at a pharmacy counter. However, topical decongestants such as oxymetazoline should generally be limited to 3 days, to avoid rebound congestion.

For expectorants, such as guaifenesin, patients need to be educated that these medications are intended to loosen mucus and facilitate clearance, not directly stop a cough. The clinical evidence supporting their effectiveness is mixed and adequate hydration remains important.

A patient pearl to always share is: If a medication isn't working, don't automatically increase the dose or add another product. Pharmacists should reassess the symptoms, verify proper dosing and administration, evaluate potential contraindications, and recommend alternative treatments or medical evaluation when warranted.

Which patient populations, such as those with hypertension, diabetes, or pregnancy, need extra caution when selecting OTC respiratory symptom relief?

Patients with hypertension, cardiovascular disease, diabetes, kidney disease, and pregnancy deserve extra attention when navigating the OTC aisle. Oral decongestants such as pseudoephedrine can increase blood pressure and heart rate, while NSAIDs may worsen hypertension, kidney function, and fluid retention. Patients with diabetes should consider sugar-free formulations—yet, be aware of those sugar alcohols and their impressive GI effects—and monitor glucose levels during illness, while pregnant patients should avoid self-selecting combination cold and flu products without professional guidance.

Older adults and patients taking multiple medications are particularly vulnerable to anticholinergic effects, sedation, falls, and drug interactions from ingredients such as first-generation antihistamines. Pharmacists should also pay special attention to pediatric patients, ensuring age-appropriate products and dosing. Many OTC pediatric medications have instructions on the box illustrating both an age-based and weight-based dosage strategy, yet to a parent taking care of their young child practically in the dark at 2 AM, which one is it, weight or age? We, as parents, need that information ahead of time, and we, as pharmacists, can provide it.

How can independent pharmacies best prepare their front-of-store inventory and staff for this season, and are there any new products for them to prioritize for 2026 specifically?

First up, just as flight attendants instruct to put one’s mask on first before helping others, perhaps we start with taking care of our pharmacy team as well. It’s a great time of year to discuss sick leave, teammate replacement strategies, and preventing the spread of infection amongst an entire pharmacy team.

Pharmacies can prepare for respiratory virus season by stocking smarter, not simply stocking more. Organize inventory by symptom, rather than brand, and train staff to recognize when patients need pharmacist help.

For 2026 specifically, pharmacies are tasked with whether to additionally stock viral tests or not, as many patients may desire and need them, yet other patients may ponder their need if the results will not necessarily affect the treatment strategy, considering the approximate $20 to $40 price tags. [It’s] most likely also a great time for a team huddle on what the pharmacy’s collective viewpoint on oral phenylephrine and whether to stock or not to stock, as a congested Shakespeare would have even appreciated the proactive planning back in the day.

The goal isn't simply to sell more cold and flu products; it's to help patients select the right products, avoid unnecessary medications, and recognize when OTC treatment isn't enough.

READ MORE: OTC Resource Center