GPs are perfectly placed to manage the vast majority of patients who have persisting symptoms after acute COVID-19 infection.
What is long COVID?
Some patients do not fully recover from their COVID-19 infection in the expected time frame and may go on to develop long COVID. Definitions vary but the following is in line with the NICE guidelines and World Health Organization definitions, and endorsed by HealthPathways:
- Persisting symptoms in second and third weeks = acute COVID.
- Symptoms ongoing in weeks 4-12 = post-acute COVID or ongoing symptomatic COVID.
- Signs and symptoms that continue for more than 12 weeks = post-COVID syndrome, or long COVID.
How common is it?
There were reports in 2020 that up to 30 per cent of those hospitalised and 13 per cent overall had persisting symptoms at 6 months. This of course was before vaccination, and before the current wave of Omicron variants. There is no formal tracking in Australia, and it is unclear what impact use of early treatment agents will have. Overall rates of long COVID are probably in the order of 5-10 per cent.
What symptoms are associated with long COVID?
The commonest reported long COVID symptoms are fatigue, breathlessness, headache, “brain fog” – associated with loss of concentration, memory issues or cognitive impairment – and anosmia or loss of taste. Other symptoms include cough, exertional chest pain or tightness, low‑grade fevers, muscle pain, palpitations, gastrointestinal upset, tinnitus, dizziness and sensory symptoms. Sleep disturbance is also common. Symptoms can change over time and a fluctuating course is common. People who go on to develop long COVID may have had a very mild initial illness.
How do we assess patients with ongoing symptoms after COVID-19?
The goal of any initial assessment after COVID-19 infection is to exclude any serious sequelae of acute infection. This will involve taking a history of the acute illness and any ongoing symptoms, performing a targeted examination, and investigating as indicated. Often no investigations are required. Refer as necessary at this stage. Pay particular attention to the presence of any red flags and take further action if present. Red flags include:
- severe, new onset, or worsening breathlessness or hypoxia
- unexplained chest pain
- palpitations or arrhythmias
- new confusion
- focal neurological signs or symptoms.
Long COVID management steps
For patients who have a longer duration of symptoms, GPs are uniquely placed to provide education, support and coordinate care using chronic disease management principles. Steps include:
- Review the patient’s long-COVID symptoms, considering which, if any, might require further investigation. Discuss current wellbeing. Allow the patient to debrief where required and listen to and ask about their concerns.
- Provide the patient with information (.pdf) about long COVID. See below for useful resources.
- Develop a management plan with the patient addressing their main symptoms and problems, and an action plan for if worsening symptoms develop.
- Refer as necessary:
- to a post-COVID-19 clinic. Most Melbourne hospitals now have long COVID clinics and referral details can be found in HealthPathways
- to a specific medical discipline according to symptoms
- for psychological support if necessary, utilising a Mental Health Care Plan
- to allied health for a rehab program (see below).
- Encourage the patient to participate in exercise and rehabilitation but do investigate any new or unexplained cardiac or respiratory symptoms before recommending a return to exercise. Consider involving an exercise physiologist – they are experts at assisting with exercise prescription and gradual return to physical activity. You might also obtain OT input, dietitian support or physiotherapy involvement. Make use of Chronic Disease Management Plans and referrals.
- Explicitly discuss fatigue management strategies, summarised as the “three Ps”.
- Pace – Save energy by breaking up your daily activities into smaller, more manageable tasks. Rest often.
- Plan – Plan your day or week in advance. Spread activities that need more energy (such as gardening, food shopping or laundry) across the whole week, with plenty of rest in between. If you can, ask family members or friends to help.
- Prioritise – Only do essential tasks and activities. Remove unnecessary tasks altogether or consider asking a family member or friend to do them for you.
- Discuss vaccination. It is unclear what impact another COVID-19 infection will have on those with long COVID. Vaccination and boosters are our best current tool to avoid repeated infections and potential worsening of long COVID symptoms.
- Be optimistic but acknowledge the uncertainty. While most symptoms improve with time, there is a lot that is unknown about long COVID.
- RACGP – Patient-resource-Managing-post-COVID-19-symptoms
- How to manage post-viral fatigue after COVID-19 – Royal College of Occupational Therapists