Guidelines of Management: Long Covid
NICE guidelines: The holistic assessment, investigation, and management approach suggested by NICE are outlined here.
Pulmonary Symptoms Management
Investigations:
Pulmonary symptoms are common during long covid. NICE recommends that breathlessness may be investigated using an exercise tolerance test suited to the person’s ability, for example the one-minute sit-to-stand test, and treatment and management should be multidisciplinary, with advice and education given on managing breathlessness.
Furthermore, the guidelines recommend offering patients with continuing respiratory symptoms a chest radiograph by 12 weeks after infection. Blood oxygen levels can be monitored using a pulse oximeter.
Treatments:
· Recommendations from the Mayo Clinic suggest that shortness of breath can be self-managed by limiting factors that exacerbate dyspnea, including stopping smoking, avoiding pollutants, avoiding extremes in temperature, and exercising, however, chronic shortness of breath may require further intervention.
· Recognized non-pharmacological strategies for managing dyspnea include breathing exercises, pulmonary rehabilitation , and maintaining optimal body positioning for postural relief.
· Patients with pulmonary fibrosis resulting from covid-19 should be managed in accordance with NICE guidelines on idiopathic pulmonary fibrosis, while antifibrotic therapies may be advantageous. Exacerbations of bronchiectasis should be treated with antimicrobial prescribing, while non-antimicrobial therapies, including airway clearance, may be considered.
· Modified rehabilitation practices, including stretching, body rotations, acupressure, and massage have shown beneficial long-term effects on respiratory symptoms in mild covid-19 patients in a small trial.
Cardiovascular Symptoms Management
Investigations:
The NICE guidelines on long covid state that exercise tolerance tests may be undertaken to measure heart function, while lying and standing blood pressure and heart rate recordings should be performed if postural orthostatic tachycardia syndrome (POTS) is suspected. Urgent referral should occur for people that have symptoms of a life threating complication, such as cardiac chest pain.
Ongoing investigation and observation of cardiac biomarkers is important.
Treatments:
· NICE guidelines recommend β blockers for several cardiac complaints, including angina, cardiac arrhythmias and acute coronary syndromes, therefore, β blockers may be useful in the treatment of cardiovascular manifestations of long covid.
· Myocarditis may resolve naturally over time; however, supportive and/or immunomodulating therapy may improve recovery, as a systematic review describes.
· A review has also suggested that anticoagulants may be used to reduce the risks associated with hypercoagulability.
Meanwhile, advice and education, agents to maintain vascular tone, and agents to manage palpitations have been shown by a randomized controlled trial and discussed in a review to be advantageous in the treatment of POTS.
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· Chronic fatigue is a common manifestation of long covid. NICE recommends that self-management and support are important in managing fatigue, owing to the poor availability of covid-19 specific treatment.
· NICE has specific guidelines include cognitive behavioral therapy (CBT) and graded exercise therapy (GET).
· Another management strategy for fatigue is pacing, whereby patients manage tasks and activities to avoid over-exertion and exacerbating fatigue.
· The holistic approach to treatment should extend to the services offered, with professionals including occupational and speech and language therapists addressing cognitive changes. Cognitive impairment in long covid, sometimes called “brain fog,” has been compared to “chemobrain.”
· The Mayo clinic recommendations suggest strategies to manage chemobrain including repeating exercises, tracking what influences deficits, and using stress relief and coping strategies. Furthermore, medications including methylphenidate, donepezil, modafinil, and memantine may be considered.
· Sleep disturbances may be managed by following relevant guidelines on insomnia and a range of treatment strategies can be considered. Patients with mental health problems alongside or as a result of long covid can be managed following the relevant guidelines:
· Depression, anxiety, PTSD, obsessive-compulsive disorder and other mental health problems. Care home residents, including those with dementia, who acquire long covid have additional needs.
· Current evidence for the recovery of renal function following covid-19 is lacking. Considering that early and close follow-ups with nephrologists have previously been beneficial, post-covid-19 patients with renal dysfunction may benefit from early and ongoing monitoring.
· Covid-19 can disrupt and alter the microbiome of the gut, which may allow for opportunistic infections.
· Covid-19 associated destructive thyroiditis can result in incident hyperthyroidism, which can be treated with corticosteroids.
· Overall, close follow-up of patients with long covid and adequate investigative procedures should be kept up to accurately diagnose and treat specific symptoms.
· Antihistamines have been implicated as a possible treatment for covid-19, with a study that employed cellular experiments suggesting that histamine-1 antagonists may be able to reduce the covid-19 infection rate by inhibiting SARS-CoV-2 from entering ACE2 expressing cells.
· Antidepressants have been proposed to reduce the effects of long covid. Antidepressant use has been associated with reduced risk of intubation or death in covid-19, while a meta-analysis of antidepressant drug treatment for major depressive disorder has shown that use of antidepressants, including serotonin-norepinephrine reuptake inhibitors and selective serotonin reuptake inhibitors, results in a reduction in peripheral inflammatory markers.
· Clinical trials exploring the efficacy of hyperbaric oxygen, montelukast and deupirfenidone to treat respiratory conditions in long covid are ongoing.
· A trial of breathing exercises and singing is also under way to assess their utility in improving breathing abnormalities in patients with long covid.
· A trial to assess the effectiveness of an 8 week exercise program in patients with long covid and fatigue is ongoing.
· Vitamin C supplementation may prove useful in treating fatigue in patients with long covid, with a systematic review concluding that high dose intravenous vitamin C could be a beneficial treatment option.
· Two trials examining the effects of nicotinamide riboside, a dietary supplement, are ongoing.
· A clinical trial is currently ongoing assessing the effectiveness of a probiotic supplement to normalize the composition of the gut microbiome and reduce inflammation in long covid. The understanding of long term sequalae of covid-19 infection in the gastrointestinal tract will evolve, with studies currently ongoing which will subsequently affect treatment.
· Other potential treatments are molecules that suppress the intense inflammatory response seen in covid-19. Leronlimab is a monoclonal antibody that blocks the function of CCL-5. It has been shown to be effective and safe in HIV and reduces plasma interleukin-6 levels in covid-19.
· Another antibody treatment, tocilizumab, blocks interleukin-6 receptors and has shown efficacy in a small trial of patients with covid-19 patients.
· The anti-oxidative and anti-inflammatory function of melatonin may also be useful in treating long covid.
· Lastly, adjuvant treatments, such as adaptogens, are being explored for their effectiveness in treating long covid
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