New consensus recommendations for management of long COVID

Researchers convened a panel of 33 clinicians from 14 specialties across primary and secondary care to generate a set of consensus recommendations for the recognition and treatment of long COVID. 

The recommendations, published in the BJGP, 'are intended to guide generalist doctors who are providing medical supervision of a community-based long COVID clinic and who have access to specialist referrals if required,' say the authors.

Rehabilitation

Of the 35 recommendations agreed on by the panel, 6 relate to clinic organisation, 13 to diagnosis of the underlying disorder, and 16 to management of the condition.

The panel agreed that GPs should consider long COVID in the presence of a wide range of presenting features, not just fatigue and breathlessness, and that detailed history and examination with baseline investigations should be carried out in primary care. Indications for further investigation and specific therapies (for myocarditis, postural tachycardia syndrome, mast cell disorder) include hypoxia/desaturation, chest pain, palpitations, and histamine-related symptoms.

With regard to the management of long COVID, the panel agreed healthcare professionals should follow the following general recommendations:

• For patients with fatigue and worsening symptoms hours to days following an activity, emphasise the importance of an initial phase of convalescence followed by careful pacing and rest.
• Support patients in shifting their mental timeline of recovery to reflect the likely prolonged course, with a possibly long phased return to work.
• Provide signposting to relevant patient resources.
• Provide signposting to social prescribing, sickness certification, and financial advice, and discuss with the patient whether sickness certification will state long COVID as the diagnosis.
• Ensure that the occupational status of patients with long COVID is recorded.
• Follow patients up regularly to monitor progress from a full biopsychosocial and occupational perspective.
• Encourage reporting of new symptoms and expectation of waxing–waning course.
• Consider contributing patient data to research on long COVID, using the WHO Case Report Form or similar.

Specific therapies

The panel also made several recommendations relating to the management of specific conditions, including:

• Patients with cardiac symptoms should be advised to limit their heart rate to 60% of maximum and investigated with electrocardiogram and echocardiogram before taking up exercise. Supervised exercise testing should be considered.
• For autonomic dysfunction including postural orthostatic tachycardia syndrome, consider first increased fluids, salts, compression hosiery, and specific rehabilitation.
• In patients with possible mast cell disorder, consider a 1-month trial of initial medical treatment, commonly with high-dose antihistamines, and dietary advice.
• For breathing pattern disorder, consider specialist physiotherapy and/or using alternative therapies such as pranayama breathing and meditation.
• Be aware that over-the-counter supplementation, including vitamin C, D, niacin (nicotinic acid), and quercetin, is common and may lead to drug interactions.

The authors say the recommendations 'go further than NICE [rapid guidance] in many areas, particularly in the need to investigate potential cardiac conditions, dysautonomia, and immune dysfunction'. They say the statements represent a 'carefully considered and reasonable approach to helping patients until further evidence is available'.