Are nicotine patches effective for treating long COVID (Coronavirus Disease 2019) or Chronic Fatigue Syndrome (CFS)?

Nicotine Patches for Long COVID/CFS: Not Recommended

Nicotine patches are not recommended for treating long COVID or Chronic Fatigue Syndrome (CFS) due to insufficient evidence of efficacy and significant risks including adverse cardiopulmonary effects and addiction potential. 1

Current Evidence on Nicotine for Long COVID/CFS

Theoretical Mechanisms

While nicotine has demonstrated some anti-inflammatory properties in animal models through:

• Activation of the cholinergic anti-inflammatory pathway
• Decreased lung vascular permeability
• Reduced leukocyte infiltration and proinflammatory cytokine concentrations 2

These theoretical benefits have not translated to clinical efficacy in humans with long COVID or CFS.

Clinical Evidence

• A randomized, double-blind, placebo-controlled trial of nicotine patches in patients with severe COVID-19 showed no mortality benefit or improvement in clinical outcomes 3
• No clinical trials support nicotine use specifically for long COVID or CFS symptoms
• The medical community explicitly does not recommend nicotine or nicotine replacement therapy for long COVID treatment 1

Risks of Nicotine Use

• Significant adverse cardiopulmonary effects
• High addiction potential
• May increase ACE2 receptor expression (potentially increasing viral entry)
• Can trigger cytokine release (IL-2, IL-6, TNF-α), potentially worsening inflammatory responses 1

Recommended Approaches for Long COVID/CFS Management

Evidence-Based Treatments

The Nature Reviews Microbiology guidelines (2023) recommend several treatment options with better evidence profiles:

1. For fatigue:

   • Coenzyme Q10 and D-ribose supplements
   • Low-dose naltrexone for pain, fatigue, and neurological symptoms
   • Low-dose aripiprazole for fatigue, unrefreshing sleep, and brain fog 2

2. For postexertional malaise:

   • Pacing (activity management)
   • Avoid exercise, cognitive behavioral therapy, and graded exercise therapy which are contraindicated 2, 4

3. For autonomic dysfunction:

   • β-blockers, pyridostigmine, fludrocortisone, midodrine
   • Non-pharmacological approaches: increased salt and fluid intake, compression stockings 2

Important Caveats

• Exercise can worsen symptoms in 75% of patients with long COVID who have ME/CFS or postexertional malaise 2
• Graded exercise therapy and cognitive behavioral therapy remain controversial for ME/CFS and should be further investigated before being recommended for long COVID 2

Alternative Treatments Under Investigation

• L-carnitine has shown promise in relieving fatigue in other conditions and may be considered for investigation in long COVID 5
• Paxlovid (antiviral) has shown potential in case reports and deserves further study 2
• Anticoagulants have shown promise in addressing abnormal clotting in long COVID 2

Conclusion

While research continues into effective treatments for long COVID and CFS, nicotine patches should not be used due to lack of efficacy evidence and significant risks. Patients should instead be directed toward symptom-specific treatments with better evidence profiles and safety records as outlined in current guidelines.