What PCPs need to know about diagnosing, managing long COVID

ByAndrew (Drew) Rhoades

Fact checked byShenaz Bagha

Key takeaways

Long COVID is common and often diagnosed late or never. It can affect multiple general and organ systems concurrently.
While there are no set assessment or management protocols, researchers highlighted holistic care, symptom control, supportiveness and the detection of treatable conditions as key factors for helping patients with long COVID in the primary care setting.

A recent article published in The BMJ provides an update on how to identify, diagnose and manage long COVID in the primary care setting.

According to Trisha Greenhalgh, MD, a professor of primary care health sciences at the University of Oxford, and colleagues, the article builds upon previous guidance that was published in the same journal in August 2020, a time when “almost no peer reviewed research or evidence-based guidance on the condition was available.”

“In this update we outline how clinicians might respond to the questions that patients ask,” they wrote.

From July 27 to Aug. 8, CDC data show that 14.8% (95% CI, 14.2-15.4) of all American adults had experienced long COVID conditions at some point, an increase from 14% (95% CI, 13.5-14.5) between June 1 to 13.

Symptoms

According to Greenhalgh and colleagues, symptoms can appear across multiple general and organ systems concurrently, though it is also possible for symptoms to dominate one system.

Fatigue is the most common symptom of long COVID and “may be associated with severe functional impairment,” the researchers wrote. Some patients, they noted, can develop post-exertional malaise or post-exertional symptom exacerbation 12 to 48 hours after physical activity.

Other conditions include:

chest pain;

autonomic dysfunction;

joint and muscle pain;

altered breathing;

poor mental health; and

loss of smell.

Diagnosis

Long COVID may be diagnosed late or not at all, Greenhalgh and colleagues reported, meaning physicians should be aware of it as a differential and that patients can develop symptoms following acute COVID-19 that are “not necessarily caused by COVID-19.”

“Some patients’ long COVID follows a fairly constant course, while others experience relapsing and remitting symptoms, sometimes with particular triggers,” they wrote.

Because long COVID affects patients in different ways and degrees, there is no standard assessment protocol.

“Ideally, every patient should have an in-person consultation, including a full history, clinical examination and review of comorbidities and social circumstances,” Greenhalgh and colleagues wrote. “Initial investigations are guided by the predominant symptoms and are primarily directed at excluding serious alternative diagnoses.”

For fatigue, the researchers recommended excluding other potential causes, ensuring bloods are appropriate, and monitoring symptom severity and relapse patterns.

Management

Like assessments, there is no standard protocol for long COVID treatment. According to Greenhalgh and colleagues, much of the current medications are directed at symptom control. Additional main components of management that the researchers advised include holistic care, supportiveness and monitoring treatable complications.

The researchers explained that physicians can help patients with long COVID by listening and validating their experiences, making a diagnosis and exclusions, encouraging self-management, managing symptoms and monitoring their progress.

Greenhalgh and colleagues said that COVID-19 vaccines may also help long COVID symptoms, and primary care physicians should discuss them with those who are unvaccinated, informing them that “improvement may be modest and not all patients benefit.”

Recovery time can vary, though two-thirds of patients with persisting symptoms at 4 weeks can expect to recover by 12 weeks.

“Those still unwell at 12 weeks may benefit from specialist multidisciplinary care,” the researchers wrote. “They may still improve, albeit at a slower rate, but many patients appear to plateau, and their illness course may fluctuate with exacerbations triggered by physical or mental stress.”