Opinion A practical framework for Long COVID treatment in primary care, 2024, Brode and Melamed

[SNT Gatchaman]

A practical framework for Long COVID treatment in primary care
Brode; Melamed

Long COVID is a complex, multisystem illness with a poorly understood pathophysiology, absence of specific diagnostic tests or criteria, or evidence-based treatments. With over 200 identified symptoms and approximately 10% of COVID-19 cases resulting in Long COVID, it is a challenge to provide comprehensive treatment at a scale commensurate with the illness burden. The diverse manifestations of Long COVID, encompassing numerous medical specialties, typically place primary care providers (PCPs) at the forefront of management, navigating an evolving landscape of research and lack of evidence-based guidelines.

This paper presents a pragmatic, structured framework for Long COVID management in primary care, integrating current knowledge and best practices. The approach is individualized, addressing Long COVID’s broad symptomatology through a four-step framework.

The first step focuses on energy management strategies, emphasizing the prevention of postexertional malaise, a cardinal feature of Long COVID. The second step, intentional rehabilitation, employs carefully titrated multidisciplinary modalities to address physical, cognitive, and emotional domains. The third step utilizes symptomatic management through both pharmacological and non-pharmacological interventions, targeting debilitating symptoms like fatigue, insomnia, and chronic pain. The fourth step outlines an approach to trialing experimental, targeted therapies that may impact Long COVID’s underlying pathophysiology. These treatments, while experimental and lacking quality evidence in Long COVID, may be available off-label on an individual basis following a thorough risk-benefit discussion.

This stepwise framework can equip PCPs to effectively address the most common and disabling symptoms of Long COVID, individualize care, and remain attuned to the evolving scientific understanding of the condition.

Link | PDF (Life Sciences)

 

[SNT Gatchaman]

Emerging evidence points to common pathways including chronic inflammation leading to immune dysregulation, disrupted neurologic signaling, and neurovascular dysfunction with coagulopathy impairing oxygen utilization [22–29]. This understanding emphasizes the need to view Long COVID not as a collection of isolated symptoms but a clinical syndrome with a spectrum of manifestations, necessitating a holistic management approach.

Targeted therapies for Long COVID, rooted in its pathophysiological mechanisms, are a fundamental goal for researchers and clinicians. Currently, this research is in its early stages, with mostly small observational, uncontrolled trials published, with the generalizability of their findings limited by the illness’s heterogeneity [30,31]. PCPs and patients alike must navigate a landscape where many proposed treatments have not been specifically studied for Long COVID, but are rather repurposed from therapies for similar conditions [32], or more concerningly, influenced by commercial interests and/or misinformation related to the COVID-19 pandemic [33,34]. In response to these challenges, this paper proposes a pragmatic, stepwise approach to patient care, grounded in the biopsychosocial model. This approach emphasizes non-pharmacologic and lifestyle interventions to manage energy and alleviate common disabling symptoms, recognizing that Long COVID has many shared features with Myalgic Encephalitis/Chronic Fatigue Syndrome (ME/CFS) [35].

[35] is ME/CFS and Long COVID share similar symptoms and biological abnormalities: road map to the literature (2023, Frontiers in Medicine)

 

[SNT Gatchaman]

Researchers are examining three broad categories of targeted treatments for Long COVID. The first targets viral persistence or remnants within the body that may provoke chronic inflammation. Ongoing trials are evaluating the efficacy of the COVID-19 antiviral combination nirmatrelvir-ritonavir (Paxlovid), and there is a growing interest in therapies to treat Epstein-Barr virus (EBV) or other herpetic virus reactivation, which is increasingly recognized to have a role in Long COVID pathophysiology [24,25,77,78]. The second category addresses immune dysregulation more directly, using agents intended to disrupt neurologic and systemic inflammation. Trials of immunomodulatory agents such as intravenous immunoglobulins (IVIG) and repurposed rheumatologic medications like JAK-kinase inhibitors are ongoing [30,79–82]. Additionally, there is interest in low-dose naltrexone and serotonin reuptake inhibitors (SSRIs), which may reduce systemic inflammation or address neurotransmitter deficiencies [29,83]. The third category focuses on treating microvascular dysfunction and clotting abnormalities. There is some preliminary evidence showing efficacy of hyperbaric oxygen therapy, anticoagulants, and mitochondrial supplements targeting these pathways [84–87].

PCPs contemplating the use of these therapies should acquaint themselves with the current evidence, or lack thereof, and engage in transparent discussions with patients about safety, potential interactions with other medications, and feasibility of the treatment. This includes considering the financial burden of interventions, as experimental or off-label treatments are unlikely to be covered by insurers. Practically, options like low-dose naltrexone, which is relatively safe and convenient as a compounded daily pill, may be more reasonable or accessible to trial than hyperbaric oxygen, which was studied as a protocol of 90-min sessions five times a week for eight weeks, and is not widely available or reimbursed in traditional medical settings [83,84].

If a patient opts to trial a targeted treatment, it is recommended to proceed with one intervention at a time, establishing clear expectations for outcomes and the timeline for evaluating effectiveness. Such a methodical approach facilitates the assessment of treatment efficacy or adverse effects, reducing the likelihood of confounding effects from simultaneous interventions. This recommendation is particularly pertinent for patients considering non-prescription supplements or “natural treatments.” Despite their widespread popularity and theoretical benefits—for example probiotics may treat gut microbiome dysbiosis associated with Long COVID [88,89]—these treatments often lack evidence-based support due to less stringent regulatory standards. Moreover, without a systematic approach, the use of these treatments can accumulate to a significant pill burden, or be harmful in excess such as vitamin B6 toxicity causing neuropathy [90].

 

[Hutan]

Ugh. Seems like they googled 'Long Covid treatments' and wrote about what they found in the mistaken belief that it was "knowledge". This is not science.

This paper presents a pragmatic, structured framework for Long COVID management in primary care, integrating current knowledge and best practices. The approach is individualized, addressing Long COVID’s broad symptomatology through a four-step framework.

Pragmatic = 'enables the doctor to sound as if they have something to offer, and keep charging you for the many visits as they work through their 'structured framework''
Individualised = 'don't blame the doctor if the treatment doesn't work for you'

 

[Trish]

So first step is pacing. Good.

Second step is hand you over to a bunch of therapists. Can be good if it is supportive and the pwLC needs support, potentially bad if they try to contradict pacing with rehabilitation and GET. Most likely outcome is wasting the pwLC's energy and money on useless therapy with no evidence base.

Third step is meds for symptoms such as pain. Can be helpful.

Fourth step is experiment with untested drugs. Hmm.

Why not be more honest and say there is no treatment, so all doctors can do is check for organ damage, advise about PEM and pacing, and prescribe symptomatic treatments where possible.