What is the management approach for patients experiencing Long Covid symptoms?

Management of Long COVID Symptoms

Any patient with symptoms persisting more than 12 weeks after acute COVID-19 should be referred to medical care for systematic evaluation and symptom-based management, with Long COVID treated as a diagnosis of exclusion after ruling out serious complications. 1

Initial Assessment Framework

Who Requires Evaluation

• Refer all patients with symptoms lasting >12 weeks after acute COVID-19 to medical care 1
• Consider case-by-case assessment for symptoms at 4-12 weeks based on severity and symptom trajectory 1
• Rule out life-threatening conditions first including thromboembolic events, myocarditis, encephalitis, or previously overlooked malignancy before diagnosing Long COVID 1

Clinical History Priorities

Collect detailed history to exclude:

• Previous underlying conditions that may explain symptoms 1
• Iatrogenic causes from acute COVID-19 treatment 1
• Complications directly related to acute infection 1
• Post-intensive care syndrome in critically ill patients (difficult to distinguish from Long COVID) 1

Risk Factor Recognition

Two consistent risk factors predict Long COVID development:

• Female sex: approximately 2-fold increased risk (OR 1.3-5) 1
• Severe acute COVID-19: strongest association with fatigue 1

Diagnostic Workup

Basic Laboratory Assessment

Obtain symptom-guided blood tests to rule out alternative diagnoses (not to confirm Long COVID, as no definitive diagnostic test exists): 1, 2

• For all symptomatic patients: C-reactive protein, complete blood count, kidney function, liver function tests 1
• For cardiac symptoms: troponin, CPK-MB, B-type natriuretic peptide 1
• If thyroiditis suspected clinically: complete thyroid function tests 1
• For diabetes risk: fasting glucose and glycated hemoglobin 1
• Avoid D-dimer in patients without respiratory symptoms 1
• Blood gases have limited benefit even with decreased oxygen saturation 1

Important caveat: Laboratory abnormalities are uncommon at 12-month follow-up, with no significant differences in lymphocyte counts or creatinine between Long COVID patients and controls 1

Respiratory Symptom Evaluation

For patients with dyspnoea persisting >4-12 weeks: 1

• Pulmonary function testing (PFT): Most frequently shows impaired diffusion capacity for carbon monoxide (DLCO <80% predicted) with restrictive pattern 1
• Severity assessment: Use modified Medical Research Council dyspnoea scale 1
• Abnormalities correlate with acute disease severity and ventilatory support requirements 1

Symptom Severity and Quality of Life Assessment

Conduct structured interview to:

• Identify symptom severity and impact on quality of life 1
• Determine if further assessment is warranted (consider whether symptoms are self-limited without effective therapy) 1
• Note that 57% of patients report decreased quality of life beyond 12 weeks 1

Management Approach

Core Management Principles

Current management focuses on symptom-based supportive care as no standard drug treatment has strong evidence: 2, 3

1. Validate patient experience - many have had symptoms dismissed by clinicians and loved ones 2
2. Energy conservation strategies are critical 2
3. Address comorbidities and modifiable risk factors 2
4. Deliver recommendations with humility given persistent unknowns 2

Critical Activity Management Warning

Exercise recommendations must be carefully tailored - overly intense activity can trigger post-exertional malaise/symptom exacerbation (PEM/PESE) and worsen muscle damage 2. This differs fundamentally from standard rehabilitation approaches.

Multidisciplinary Treatment Components

Consider the following interventions based on symptom presentation:

• Pulmonary rehabilitation for respiratory symptoms (dyspnoea, cough, chest pain) 4, 5
• Fatigue management programs 4
• Psychological therapy for mental health symptoms 4
• Supported self-management for respiratory symptoms 5
• Occupational/vocational therapy for return-to-work challenges 2

Medication Management

No specific medications are strongly recommended for Long COVID due to lack of evidence 2, 3. When medications are used:

• Follow standard practice for indications and dosing 2
• Prioritize shared decision-making with patients 2
• Use caution with medications that may improve some symptoms (e.g., cognitive impairment) but worsen others (e.g., PEM/PESE) 2

Emerging Interventions

Stellate ganglion block (SGB) has shown promise for dysautonomia symptoms in case reports, though effects may wane requiring repeated procedures 6. Current evidence is limited to case reports and small studies rather than randomized trials 6. Should be considered as part of comprehensive treatment, not standalone therapy 6.

Disability and Return-to-Work Considerations

Long COVID is recognized as a potential disability under the Americans with Disabilities Act 2. The return-to-work process is challenging because:

• Symptoms fluctuate and affect multiple functional areas 2
• Often manifests as "invisible disability" not readily acknowledged 2
• Work may significantly worsen symptoms or impede recovery 2

Clinicians should:

• Identify suitable workplace accommodations and resources 2
• Provide necessary documentation 2
• Recommend occupational/vocational therapy when needed 2
• Consider disability application if work significantly worsens symptoms 2

Common Symptom Prevalence

Most prevalent symptoms at 3-6 months: 1

• Fatigue: 31% (most common)
• Dyspnoea: 25%
• Anosmia: 15.2%
• Dysgeusia: 13.5%
• Myalgia: 11.3%
• Joint pain: 9.4%
• Cough: 8.2%
• Depression: 8%

Symptoms can persist up to 12 months after acute disease, though some respiratory abnormalities may improve over time 1, 5, 7

Key Clinical Pitfalls

• Do not require positive COVID-19 test for Long COVID diagnosis 2
• Do not use D-dimer routinely - only for patients with respiratory symptoms 1
• Do not prescribe standard exercise programs without considering PEM/PESE risk 2
• Do not dismiss patient symptoms - validation is therapeutic 2
• Do not expect laboratory confirmation - Long COVID has no definitive diagnostic test 2, 3