COVID-19 Is Far From Over: Prevention and Management of Long COVID

Key Takeaways:

• Vaccination against SARS-CoV-2 and prevention of infection are still the best ways to reduce the threat of hospitalization and severe illness from COVID-19, including long COVID
• Assessment of a patient’s risk factors and comorbidities should be used to determine whether to initiate treatment with an antiviral agent or monoclonal antibody.
• Healthcare professionals should listen to patients’ reports of their symptoms, including mental health symptoms, and develop individualized care plans.

COVID-19 is far from over, and the impact of long COVID is just beginning. Estimates of the incidence of long COVID—or postacute sequelae of SARS-CoV-2—range from approximately 10% to 30%. Although most cases appear to improve over time, serious and disabling long COVID can limit or prevent a return to work. We are just beginning to understand the long-term individual and societal impacts of long COVID. This is our topic in this commentary and will be part of our upcoming live symposium titled, “Expert Insights Into Optimal Outpatient Management of Acute and Long COVID-19” on October 20, 2022, at IDWeek 2022 in Washington, DC.

Prevention and Early Treatment
A critical priority is to fully vaccinate and boost all Americans with the new omicron-specific bivalent booster. With only 35.2% of Americans having received a third booster vaccine, most Americans are not fully vaccinated. With new and more transmissible omicron subvariants such as BQ.11 and BA2.75.2 arising every 3-4 months, and with 400-500 Americans still dying every day from COVID-19, this is not a good time to relax our vigilance against SARS-CoV-2. The best way to reduce the threat of hospitalization and severe illness, including long COVID, still is to prevent SARS-CoV-2 infection.

In the meantime, long COVID clinics—and healthcare professionals (HCPs) who see this patient population—are trying to provide supportive care via rehabilitation and symptomatic treatment while eagerly awaiting clinical trials with specific therapeutics. There are striking similarities to the early AIDS epidemic, with one major, noteworthy difference: Evidence that full COVID vaccination reduces the incidence and severity of long COVID is growing. It remains to be determined whether early therapy with antivirals and monoclonal antibodies affects long COVID incidence or severity. However, these treatment options are dramatically improving our approach to COVID-19 management.

HCPs should conduct a risk assessment to determine whether to initiate treatment with an antiviral agent or monoclonal antibody. Indications for outpatient treatment of SARS-CoV-2 infection include unvaccinated status and age older than 50 years, as well as a range of comorbidities, including chronic kidney disease, chronic obstructive pulmonary disease, congestive heart failure, diabetes, HIV infection, cancer, pregnancy, transplant, and other immunocompromising conditions and therapies. Fortunately, the National Institutes of Health and Infectious Diseases Society of America treatment guidelines offer updated guidance to HCPs on the proper use of antivirals and monoclonal antibodies. Of importance, prompt testing and diagnosis are needed to ensure that treatment is initiated within 5 days of symptom onset.

Social and Societal Impacts
COVID-19 has profound ongoing mental health consequences. Numerous studies have demonstrated the severe impact of the pandemic on previous educational gains, as well as on the well-being of children and their caretakers. Equally well documented is the devastating impact of the pandemic on women in terms of an increase in intimate partner violence, depression, suicidal ideation, and substance abuse. It is imperative for HCPs to engage with patients on these real-life impacts and to offer support and validation for our patients’ suffering.

Equally severe is the demoralizing effect of the COVID-19 pandemic on HCPs and public health officials. One recent study reported a 20% increase in emotional exhaustion among nurses from 2020-2022, and a survey of more than 6000 acute and critical care nurses reported that nearly two thirds have considered leaving their current jobs during the COVID-19 pandemic. Continuing depletion and demoralization of the healthcare workforce threaten our ability to respond effectively to the ongoing pandemic and eventually return to a positive and well-balanced work life. Health leaders must act urgently to improve HCPs’ well-being and quality of life by providing adequate staffing, emotional support, and sufficient time away from work to allow dedicated HCPs to rest and recharge themselves.

Long COVID Management
The heterogenous pathogenesis of long COVID clearly contributes to the breadth of clinical presentations, as well as to frustrations with patient care and treatment. Direct neuro-invasion likely contributes to anosmia and appears to contribute to other neurologic consequences. Immune dysregulation and autoinflammation suggest a therapeutic role for anti-inflammatory medications and immunomodulators. Hospitalization and post-ICU syndrome also clearly contribute to prolonged illness among patients who survive severe COVID-19 and who may require hemodialysis, anticoagulation, stroke rehabilitation, anti-arrhythmia therapy, and treatment for pulmonary fibrosis. Persistent virus in immunologically privileged sites and endothelial injury are also likely contributors.

In long COVID care, key priorities are to believe our patients’ reports of their symptoms and to develop individualized care plans to address their unique symptom complexes. The most common lasting symptoms, including fatigue and “brain fog,” are frustrating to manage for both patients and HCPs. Ruling out other medical conditions and offering safe treatment options are the mainstays of management.

There are early reports of approaches that may help us manage the symptoms of long COVID but more study is needed. For example, in some patients, attention deficits may respond to stimulants such as methylphenidate or modafinil. Hydration, increased salt intake, and compression stockings may offer relief for postural hypotension and dysautonomia, and fludrocortisone or midodrine may be useful with postural orthostatic tachycardia syndrome. Gabapentin or pregabalin may improve symptomatic neuropathy. Careful sleep assessment may be useful with trials of melatonin, mirtazapine, and sleep agents.

The profound fatigue that may accompany long COVID has several potential causes, including neurologic, cardiovascular, sleep-related, psychiatric, muscular, and mitochondrial dysfunction. Cardiopulmonary evaluation is important in selected patients. HCPs should be careful to advise low-impact, short-duration exercise with a gradual increase to avoid overexertion and to prevent post exertional malaise. Counseling and emotional support should be offered to all such patients, and a trial of antidepressant therapy may be warranted in some cases. Some reports of benefits with duloxetine, fluvoxamine, and venlafaxine include a concomitant reduction in headache and dysesthesias.

Despite these uncertainties, we find reasons for hope and resilience in the future of long COVID in the United States. Our response to long COVID must be 2 pronged: vigilant patient care and aggressive research into pathogenesis and effective therapies. We are heartened by the vigorous response of the research community to better understand long COVID pathogenesis and explore new management approaches.

Want to Learn More About COVID-19?
To hear more perspectives, join our interactive symposium at the forthcoming IDWeek 2022 meeting in person in Washington, DC, or by live webcast to hear us discuss patient assessment, outpatient treatment, and post–COVID-19 conditions.

Your Thoughts?
How do you assess patients’ risk of poor outcomes from COVID-19? Join the discussion by posting a comment.