What are the management strategies for symptoms of long COVID (Coronavirus disease 2019)?

Management of Long COVID Symptoms

The management of long COVID symptoms requires a symptom-based approach tailored to the specific manifestations experienced by each patient, with no single treatment effective for all presentations. 1

Diagnostic Approach

Before initiating treatment, it's essential to:

1. Confirm long COVID diagnosis:

   • Ongoing symptomatic COVID-19: Symptoms 4-12 weeks after infection
   • Post-COVID-19 syndrome: Symptoms persisting >12 weeks 1
   • Rule out other serious conditions that may mimic long COVID symptoms 1

2. Initial assessment should include:

   • Blood tests: Complete blood count, kidney and liver function, C-reactive protein, ferritin, B-type natriuretic peptide, and thyroid function 1
   • Chest radiography for respiratory symptoms 1
   • Exercise tolerance testing (e.g., 1-minute sit-to-stand test) 1
   • Postural vital signs for dizziness/palpitations (3-minute active stand test) 1

Management of Common Symptoms

Fatigue (Most common symptom)

• Energy conservation strategies:

  • Pacing activities throughout the day
  • Prioritizing essential tasks
  • Planning rest periods 2

• Phased return to activity:

  • Gradual, individualized approach to avoid post-exertional malaise
  • Avoid excessive physical exertion that may worsen symptoms 1, 2

• Warning: No medications are currently recommended specifically for long COVID fatigue due to lack of evidence 3

Respiratory Symptoms

• For breathlessness:

  • Controlled breathing techniques (pursed-lip breathing)
  • Positioning (sitting upright, leaning forward with arms braced)
  • Relaxation techniques 1

• For persistent cough:

  • Honey and lemon in warm water
  • Consider codeine linctus or codeine phosphate tablets if distressing 1

• For severe cases:

  • Consider pulmonary function testing with diffusion capacity 1
  • Pulmonary rehabilitation for those with abnormal results 1

Cognitive Symptoms ("Brain Fog")

• Cognitive rehabilitation strategies:

  • Memory aids and written lists
  • Breaking tasks into smaller steps
  • Minimizing distractions 2

• Sleep hygiene optimization:

  • Regular sleep schedule
  • Avoiding screens before bedtime
  • Creating a restful environment 1

Cardiovascular Symptoms

• For palpitations/postural symptoms:

  • Adequate hydration (up to 2 liters daily)
  • Salt intake optimization
  • Compression garments for orthostatic symptoms 1

• Warning: Urgent referral needed for severe hypoxemia, signs of severe lung disease, or cardiac chest pain 1

Neurological Symptoms

• For vertigo/dizziness:
  • Vestibular rehabilitation therapy
  • Meclizine (25-100 mg daily in divided doses) for symptomatic relief 4
  • Consider short course of oral corticosteroids for persistent vertigo 4

Psychological Symptoms

• For anxiety/depression:
  • Validate patient experiences and provide reassurance
  • Consider psychological support services
  • Address sleep disturbances 1, 2

Special Considerations

• Return to work/activities:

  • Gradual, phased return based on symptom tolerance
  • Consider workplace accommodations
  • Document functional limitations for disability applications if needed 2

• Vulnerable populations:

  • Provide additional support (interpreters, advocates)
  • Allow extra time during consultations 1

• Monitoring:

  • Regular follow-up to assess symptom progression
  • Adjust management plan as symptoms evolve 1

Pitfalls to Avoid

• Don't dismiss symptoms as psychological or exaggerated; long COVID is a recognized medical condition 2

• Avoid excessive physical exertion early in recovery, which can trigger post-exertional malaise and worsen symptoms 2

• Don't rely on negative test results to rule out long COVID; diagnosis is clinical and many patients have normal investigations 1, 5

• Avoid polypharmacy without clear indications; focus on symptom management and supportive care 3

• Don't expect rapid recovery - symptoms often fluctuate and may persist for months 5

Remember that long COVID research is evolving rapidly, and management approaches should be updated as new evidence emerges.