It helps to compartmentalise and address symptoms individually, according to an Australian expert whose clinic has seen over 1000 patients.
Some simple steps can help mitigate long covid and treat its symptoms, according to the head of the long covid clinic at St Vincent’s Hospital in Sydney.
With 750 million covid survivors globally, more awareness of these treatable traits would help address this public health problem, respiratory physician Associate Professor Anthony Byrne told delegates at the Immunisation Coalition ASM in Melbourne last month.
For respiratory physicians, this may be addressing symptoms such as breathlessness and cough, or treating pneumonia, secondary infections and reducing the risk of VTE/PE.
But the first step in combating long covid was diagnosing and mitigating the infection when it occurred, said Professor Byrne, whose multidisciplinary long covid clinic was one of the first and has seen over 1000 patients.
Diagnosing long covid can be challenging, because there are more than 200 symptoms described in this population, he told the meeting. But it is defined as the presence of these symptoms at least three months after infection that is not otherwise explained.
The most common symptom, by far, is fatigue. But mild cognitive impairment (brain fog), breathlessness (with or without cough), pain (including chest pain) and mental health problems (with or without sleep disturbances) are frequent complaints.
Professor Byrne recommended PCR tests for patients who were RAT-negative, and said he gave patients with chronic illnesses PCR request forms in advance to reduce diagnostic delays if they developed symptoms.
“When that patient calls you and says they’re covid-positive, have a think about giving them treatments that might reduce the chance of them getting long covid, rather than waiting for three months for them to tell you that they’re still sick,” he said.
Some data suggests antivirals such as nirmatrelvir/ritonavir (Paxlovid) cut long covid rates by a quarter compared to no treatment.
Metformin also appears to help, Professor Byrne said. Among patients who took the drug for two weeks at the time of diagnosis, 6.3% had long covid a year later compared to 10.4% of those who didn’t take metformin.
Similarly, inhaled steroids with budesonide reduced the risk of long covid while also treating symptoms in the acute phase of the illness, such as cough, he said.
Those mitigation strategies were particularly important in patients at a high risk of long covid, such as those who were un- or undervaccinated, had severe acute covid infection (which included hospitalised patients or those with more than five symptoms), were older, female or who had comorbidities (such as hypertension, diabetes, or who were immune suppressed or had autoimmune disease).
More surprising risk factors included stress at the time of infection and low self-esteem. Professor Byrne has also seen a high number of patients with ADHD.
The good news was that there were “treatable traits” that respiratory physicians could address individually, Professor Byrne said.
“Sometimes you can get this organising pneumonia that that needs steroids to treat in the post-acute period of time,” he said. Patients were at an increased risk of bacterial, fungal and other infections in the acute and post-acute phase.
“Venous thromboembolic disease is also seen in the acute phase, but we commonly see this in our long covid population.”
Professor Byrne said he would evaluate conditions in order of life threatening, important and then annoying and disabling causes.
“In evaluating breathlessness … we do identify lots of our patients that have subsegmental mismatch defects on V/Q scanning that are not found on CT pulmonary angiography, and we see these patients get better with anticoagulating them, as you would expect.
“We see a lot of myocarditis and pericarditis when it’s looked for, and we also see a lot of anxiety and panic disorder, and the interplay with that and small airway dysfunction, asthma, dysfunctional breathing.
“The chest pain is really interesting. Sometimes it can be because of pathology, such as PE – often it’s not – and we see pleuritis, and we see a neuropathic-type syndrome in these patients, with presumably nerve injury as the potential cause of their pain.”
Patients with long covid often had normal lung function when tested, but there were some with evidence of small airway dysfunction when oscillometry was used, Professor Byrne said. Those patients, according to early data from their clinic, tended to improve over six months when put on inhaled steroids.
It was important to remember that this was a respiratory virus, he told ARR.
“It does cause recrudescence and new onset asthma … And occasionally there’s infected bronchitis and pulmonary embolism.
“There’s also a lot of covid patients and post-covid patients that have sleep apnoea and sleep disorders … this is part of what you’re trained to do.
“This is a virus that’s been around for five years now. It’s not going anywhere.”
