What is the recommended treatment approach for a patient with Long Covid (Post-Acute Sequelae of SARS-CoV-2 infection), considering their individual symptoms and medical history?

Long COVID Treatment

Long COVID requires symptom-based supportive care with energy conservation as the cornerstone, delivered through a multidisciplinary approach after ruling out serious complications, with no medications specifically approved for this condition. 1, 2, 3

Initial Assessment and Exclusion of Serious Conditions

Long COVID is a diagnosis of exclusion—you must first rule out life-threatening complications before attributing symptoms to post-acute sequelae. 1, 2

Critical conditions to exclude:

• Thromboembolic events (pulmonary embolism, deep vein thrombosis) 1, 2, 4
• Myocarditis (check troponin, CPK-MB, BNP if chest pain or palpitations present) 2, 4
• Encephalitis 1, 4
• Previously overlooked malignancy 1, 4
• Post-intensive care syndrome in critically ill patients (difficult to distinguish from Long COVID) 1, 2

Obtain detailed history to identify:

• Pre-existing conditions that may explain current symptoms 1, 4
• Iatrogenic causes from acute COVID-19 treatment 1, 4
• Complications directly related to acute infection 4

Diagnostic Workup

Basic laboratory panel for all patients: 1, 2, 4

• Complete blood count 2, 4
• C-reactive protein 2, 4
• Kidney function tests 2, 4
• Liver function tests 2, 4

Symptom-specific additional testing:

• Cardiac symptoms (chest pain, palpitations): troponin, CPK-MB, B-type natriuretic peptide 2, 4
• Suspected thyroiditis: complete thyroid function tests 2, 4
• Diabetes risk assessment: fasting glucose and glycated hemoglobin 2

Avoid unnecessary testing:

• D-dimer in patients without respiratory symptoms 2, 4
• Blood gases (limited benefit even with decreased oxygen saturation) 2, 4

Pulmonary function testing with DLCO:

• At 3 months for all patients with severe or critical acute COVID-19, regardless of current symptoms 2
• For any patient with persistent dyspnea at 4-12 weeks 2

Chest imaging indications:

• Clinical suspicion of pneumonia, pulmonary embolism, or pulmonary fibrosis 2
• Decision-making for hospital admission in mild symptomatic patients with high-risk comorbidities (diabetes, hypertension, heart disease, obesity, age >60) 2

Core Management Strategy

1. Validate Patient Experience and Set Realistic Expectations

Acknowledge the patient's suffering explicitly—many have had symptoms dismissed by loved ones and clinicians. 4, 3 Provide reassurance that symptoms are being taken seriously while acknowledging uncertainties in the field. 4, 3

2. Energy Conservation and Pacing (Most Critical Intervention)

Implement strict energy conservation strategies and pacing techniques immediately. 4, 3 This is the foundation of Long COVID management.

Physical activity must be carefully tailored to current tolerance:

• Overly intense activity triggers postexertional malaise/postexertional symptom exacerbation (PEM/PESE) and worsens muscle damage 3
• Set realistic, achievable goals based on current activity tolerance 4
• Avoid standard exercise prescriptions that assume normal physiologic recovery 3

3. Symptom-Based Supportive Care

Common symptoms and their prevalence at 3-6 months: 2

• Fatigue (31%) 2
• Dyspnea (25%) 2
• Anosmia (15.2%) 2
• Dysgeusia (13.5%) 2
• Myalgia (11.3%) 2
• Joint pain (9.4%) 2
• Cough (8.2%) 2
• Depression (8%) 2

Conduct structured interview to assess:

• Symptom severity and impact on activities of daily living 2
• Work capacity 2
• Overall quality of life using validated scales (e.g., modified Medical Research Council dyspnea scale for respiratory symptoms) 2

4. Medication Considerations

No medications are specifically approved for Long COVID. 4, 3 Medication use follows standard practice for symptom management with critical caveats:

• Use shared decision-making and prioritize patient preference 3
• Exercise extreme caution with medications that may improve some symptoms (e.g., cognitive/attention impairment) but worsen others (e.g., PEM/PESE) 4, 3
• Treat comorbidities and modifiable risk factors according to standard guidelines 4

5. Multidisciplinary Rehabilitation

Consider multidisciplinary rehabilitation for physical, psychological, and cognitive support. 4, 3, 5 This should include:

• Physical therapy (with careful attention to activity tolerance) 3
• Occupational therapy 3
• Speech and language pathology 3
• Neuropsychology 3
• Psychiatry 3

6. Self-Management Guidance

Provide specific self-management strategies: 4

• Ways to self-manage symptoms 4
• Symptom tracking tools 4
• Sources of support (patient advocacy groups, Long COVID clinics) 4

Return to Work Considerations

Address work capacity early in the treatment plan: 4, 3

• Discuss phased return to work or education 4
• Identify suitable workplace accommodations 4, 3
• Consider occupational or vocational therapy referral 4, 3
• Provide necessary documentation for employers 3

Long COVID is recognized as a potential disability under the Americans with Disabilities Act. 4, 3 If work significantly worsens symptoms or impedes recovery, disability application may be warranted. 4, 3

Follow-Up and Monitoring

Establish clear follow-up plan: 4

• Frequency of follow-up visits 4
• Healthcare professionals involved 4
• Monitoring for symptom progression or new complications 4

Reassessment at 12 weeks should include: 4

• Formal diagnosis of Long COVID if symptoms persist 4
• Routine pulmonary function testing for respiratory symptoms 4
• Chest imaging if indicated 4

Emerging Therapies

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

Numerous clinical trials are investigating additional treatments including immune modulating agents. 3, 7 However, evidence-based recommendations await completion of these trials.

Common Pitfalls to Avoid

• Do not dismiss symptoms or attribute them to anxiety/deconditioning without thorough evaluation 4, 3
• Do not prescribe standard exercise programs—this can trigger PEM/PESE and worsen outcomes 3
• Do not require positive COVID-19 test for diagnosis—a positive test during acute infection is not required to diagnose Long COVID 3
• Do not overlook that 57% of patients report decreased quality of life beyond 12 weeks—this is a disabling condition for many 2

Risk Factors for Developing Long COVID

Consistent risk factors: 1

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

Inconsistent risk factors with mixed evidence: 1

• Age 1
• Obesity 1
• Presence of comorbidities 1