What is the recommended treatment approach for patients with long covid (post-acute coronavirus syndrome)?

Long COVID Treatment Approach

The recommended treatment for long COVID is primarily symptom-based supportive care, with no specific pharmacological therapies currently proven effective, requiring a structured four-step framework: energy management, intentional rehabilitation, symptomatic treatment, and consideration of experimental therapies only in clinical trial settings. 1, 2

Initial Assessment and Diagnosis

Rule out alternative diagnoses first before attributing symptoms to long COVID, including thromboembolic events, myocarditis, secondary bacterial pneumonia, and unmasking of preexisting conditions. 1

Essential Laboratory Testing

Obtain baseline labs for all symptomatic patients: 1

• C-reactive protein, complete blood count, kidney function, liver function tests
• Troponin, CPK-MB, and B-type natriuretic peptide if cardiac symptoms present (chest pain, palpitations)
• Thyroid function tests if thyroiditis suspected clinically
• Fasting glucose and HbA1c for patients at diabetes risk
• Avoid D-dimer unless respiratory symptoms present

Symptom-Specific Investigations

For persistent dyspnea (>4-12 weeks): 1

• Pulmonary function testing with DLCO measurement (most frequently impaired parameter)
• Modified Medical Research Council dyspnoea scale assessment
• Consider chest CT if severe acute disease or ICU admission occurred

Step 1: Energy Management (Foundation of Treatment)

Energy conservation and pacing strategies are critical first-line interventions to prevent post-exertional malaise (PEM), the cardinal feature of long COVID. 2, 3, 4

Key Principles:

• Validate the patient's experience explicitly - many have had symptoms dismissed by clinicians and loved ones 2
• Teach pacing techniques to stay within current energy limits without triggering symptom exacerbation 2, 3, 4
• Use registries/symptom calendars to track symptoms and identify triggers 5, 4
• Avoid overly intense activity - this can trigger PEM and worsen muscle damage 2, 3

Critical pitfall: Do NOT recommend standard exercise programs or "push through" approaches - these worsen outcomes in long COVID patients. 2, 3

Step 2: Intentional Rehabilitation

Carefully titrated, multidisciplinary rehabilitation addressing physical, cognitive, and emotional domains. 2, 4

Rehabilitation Components:

• Physical rehabilitation programs with gradual, symptom-guided progression 2, 5, 4
• Vestibular rehabilitation for patients with dizziness/vertigo symptoms 6
• Cognitive rehabilitation for brain fog and attention deficits 2, 4
• Occupational therapy for return-to-work planning and workplace accommodations 2

Phased return to activity must be individualized based on current activity tolerance, not pre-COVID baseline. 3, 4

Step 3: Symptomatic Management

Olfactory Dysfunction (Anosmia/Ageusia)

Olfactory training should be recommended for all patients due to its simplicity and safety profile, despite limited evidence. 1

• Discuss likelihood of spontaneous recovery with patients 1
• Recommend smoking cessation (general health benefit justifies recommendation) 1
• Avoid other interventions outside clinical trials - insufficient evidence for corticosteroids, zinc, vitamin A, or other supplements 1

One low-quality RCT showed no benefit of mometasone furoate nasal spray plus olfactory training versus olfactory training alone. 1

Fatigue Management

No interventions can be recommended for long COVID fatigue - evidence is insufficient for any pharmacological or non-pharmacological therapy. 1

• Clinical overlap exists with myalgic encephalomyelitis/chronic fatigue syndrome 1
• Graded exercise therapy is controversial and should not be recommended until further investigation in long COVID populations 1
• Counseling therapies may have benefit based on related conditions, but lack long COVID-specific evidence 1

Neurological/Cognitive Symptoms

No pharmacological treatments can be recommended for neurological sequelae - no clinical studies exist evaluating any intervention. 1

Theoretical treatments mentioned (luteolin, cannabidiol, methylene blue) lack clinical evidence and should not be used outside research settings. 1

Vertigo/Dizziness

No supplements are recommended for long COVID vertigo - no high-quality studies demonstrate efficacy. 6

• Refer to multidisciplinary rehabilitation services with vestibular expertise 6
• Avoid overmedication with unproven supplements due to potential drug interactions 6
• Rule out thromboembolic events or neurological complications first 6

Psychiatric/Emotional Symptoms

Evidence is insufficient to recommend any specific intervention for emotional/psychiatric sequelae. 1

• Supportive psychotherapy techniques and peer support networks may help 5
• Clomipramine has been theoretically suggested but requires further study 1

Step 4: Medication Considerations

To date, limited data guide medication management specifically for long COVID. 2

General Principles:

• Follow standard practice for indications and dosing of medications for comorbid conditions 2
• Prioritize shared decision-making with patient preference 2
• Use caution with medications that may improve some symptoms (e.g., cognitive impairment) but worsen others (e.g., PEM) 2
• Maintain adequate hydration and healthy diet 3
• Treat underlying medical conditions using established paradigms 3

No specific medications are proven effective for long COVID itself - experimental therapies should only be offered in clinical trial settings. 1, 2, 4

Follow-Up and Monitoring

• Regular assessment of symptom progression and functional status 6, 5
• Monitor for new or worsening symptoms that may indicate complications 6
• Consider care coordinator for continuity across multiple specialists 6
• Referrals to specialists based on specific organ system involvement 5

Return to Work Considerations

Long COVID is recognized as a potential disability under the Americans with Disabilities Act. 2

• Identify suitable workplace accommodations (flexible hours, remote work, reduced workload) 2
• Provide necessary documentation for employers 2
• Recommend occupational/vocational therapy when needed 2
• Consider disability application if work significantly worsens symptoms or impedes recovery 2

Common Pitfalls to Avoid

• Do not dismiss patient symptoms - validation is essential for therapeutic relationship 2
• Do not recommend standard exercise programs without careful symptom-guided titration 2, 3
• Do not prescribe unproven supplements or medications outside clinical trials 1, 6
• Do not assume positive antigen tests represent reinfection in early weeks post-infection 7
• Do not delay evaluation for serious complications (thromboembolism, myocarditis) 1, 6, 7