Q) How are we treating patients with long-COVID and are we doing a good job with it?
A) Over the last couple of weeks, we have been discussing one of the long term complications that has arisen from the introduction of the COVID-19 virus into our world, the persistent state of illness that is known as long-COVID (or post COVID syndrome/ long-haulers syndrome).
It should not be too surprising to those who have read our last two articles that we are really struggling to treat this condition effectively. Why is that surprising you ask? Well the reasons are three-fold.
First, we seem to be really ineffective in identifying those that have it which is an obvious stumbling block when it comes to treatment. Second, the symptoms are incredibly varied for a single disorder meaning that what one patient needs help with may have no correlation with what could potentially benefit another. Lastly, we really do not have a firm grip on just what the underlying biological mechanism of this disease is.
Is it a persistent infection, an underlying autoimmune disorder that was triggered by the acute COVID infection or is it simply a result of the damage inflicted upon our tissues by the widespread inflammation associated with COVID-19. It’s hard to fix something when you really don’t know what’s actually wrong. This reality is reflected in the data.
In a study published recently in Morbidity and Mortality Weekly Report (which sounds like a super fun read!), people with ongoing long-COVID were more likely to report substantially worse health than those who were needing rehabilitation because of cancer. Those with COVID-19 symptoms were 2.3 times more likely to report pain, 1.8 times more likely to report worse physical health and 1.6 times more likely to report difficulty with physical activities. The COVID-19 rehab group also fared significantly worse on a 6-minute walk test suggesting they had less physical endurance than those who had recently undergone the onslaught that cancer and its various treatments can inflict upon a body.
So, clearly, this is a cohort that needs treatment of some sort. Unfortunately, this is all ground breaking stuff and is an area of expertise that would likely be beyond the capabilities for most family doctors who are still buried under the backlog left over from our assorted lock downs.
To combat this, Canada has opened a number of Post-COVID care clinics. Fortunately, for local readers of this column, one of the few in Canada is located just down the road at the London Health Sciences Centre. A post-COVID care clinic is essentially a medical division set up specifically to treat patients with long term symptoms from COVID-19.
These clinics range in size, how they see patients (the one in London is virtual but there are clinics that are treating those affected on both an outpatient and inpatient basis) and their offerings but they all allow patients to connect with different specialists who have acquired an expertise (hopefully at least…) in this area of medicine.
The specialists you may be referred to include respirologists, experts in chronic pain management, dieticians, physiotherapists, occupational therapists and numerous others. At this time, since so many questions still need to be answered when it comes to long-hauler’s syndrome, there still is no standardized first-line treatment or magic bullet when it comes to therapy.
The goal of these clinics is rehabilitation with a focus on the individual symptoms of the patient that is in front of you. So, for instance, many patients have lost significant amounts of weight and find when they eat a full meal, their symptoms flare-up for a few days. This is very common in dysautonomia, a hall mark range of ill-effects that many battle daily. In this case dieticians and nutritionists work with the patient to educate them on foods that are easier to digest while still being provided the necessary increase in calories that weight gain requires. They also might retrain patients on their eating habits and encourage them to eat smaller and more frequent meals rather than the “big 3” that most of us do.
For those who experience frequent dizziness (another hallmark of dysautonomia relating to sudden drops in blood pressure) they might be fitted with compression stockings which help prevent the pooling of blood in the lower legs and to adjust the sodium content of their diet.
Another type of treatment that seems to benefiting some patients is the introduction of breathing exercises. It has been found that some long COVID sufferers actually have carbon dioxide (CO2) levels that are lower than they should be. This is somewhat surprising since CO2 is a somewhat toxic waste product produced by our breathing process. CO2 helps regulate our acidity and poor acidity can disrupt many of our metabolic processes. These exercises help patients retain their CO2 which consequently helps many of the underlying symptoms that have been plaguing them.
Other experts focus more on the cognitive component of this disorder helping patients with their specific complaints with respect to challenges with memory, paying attention, finding the right word or whatever else is particularly challenging the patient.
One study found that patients on average improved their skills in these areas by 30 to 40% but it was a slow and challenging process carried over 5 months with twice weekly 30 minute sessions. Lastly, patients will be offered general lifestyle type advice. They are taught that they need to pace themselves since overexertion can cause regression in their condition for days or even weeks. At the same time, they are often counselled paradoxically to gradually increase the amount of exercise they do even if they become somewhat breathless because if they stop using their muscles they will only get weaker.
Clearly there is a fine balance that needs to be found here. They will be taught to choose the time of day they engage in their activities (such as housework) ideally avoiding any exertion during the hottest part of the day. They may be taught flexibility exercises, like yoga and tai chi, that can help reduce their joint and muscle pain. These are but a few of the things that are benefitting at least some of the affected.
As for “miracle cures”, there is none at present but a treatment that has been approved by the FDA for migraines is showing some progress. We have noted in previous articles that long-COVID patients seem to experience higher levels of vascular inflammation than is normal. Some doctors are trialing a device called the GammaCore Sapphire CV which sends electrical stimulation to the vagus nerve. This in turn, reduces the widespread inflammation and patients have reported improvements in their symptoms such as increased airflow. It’s a long way from being proven, but there is hope that this device may speed the recovery process.
It appears from the nature of the treatment of this syndrome that the phrase long haul describes more than just the condition itself. For more information about this or any other health related topics, contact your pharmacist.