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Framework for GPs to manage ‘long COVID’


Morgan Liotta


25/11/2020 3:03:38 PM

A recent GP20 presentation examines how GPs can recognise the signs and manage an emerging clinical concern.

Young man catching his breath.
Shortness of breath is one of the many symptoms reported by people who have had COVID-19.

There is emerging evidence that people experience a range of symptoms for some time after testing positive for COVID-19.
 
Reported symptoms include headache, confusion, loss of smell, respiratory issues, shortness of breath, cardiac symptoms, myalgia, bowel symptoms, chronic fatigue, tingling sensation in the limbs, ringing in the ears, and mood swings.
 
As part of this year’s GP20 live sessions, experts examined the risks for post-COVID-19 consequences.
 
‘Survived COVID – What about after-care?’ discussed evidence from various studies and recommendations for appropriate screening and management of patients who have had the virus.
 
Facilitator Dr Michael Clements, Chair of RACGP Rural, opened the session by acknowledging that many GPs in Australia will care for a patient following a COVID infection at some stage, which makes understanding the effects paramount.
 
‘The long-term sequelae are still now only being defined and described, and can include anything from pulmonary damage post-ventilation to chronic fatigue-like syndromes and cardiac complications,’ he said.
 
Professor Mark Morgan, Chair of the RACGP Expert Committee – Quality Care, and Co-Chair on the National COVID-19 Clinical Evidence Taskforce, presented the session. He started with the medium- and long-term potential effects of COVID.
 
‘Fatigue and brain fog seem to be a common report from patients,’ Professor Morgan said. ‘These point to the health-related anxiety that new conditions like this generate.
 
‘Post-traumatic stress disorder also seems to be very common in people who’ve survived COVID.’
 
Professor Morgan cited an October 2020 NICE UK guideline scope paper, which released the following definitions:

  • First four weeks – acute COVID
  • 4–12 weeks – ongoing symptomatic COVID that a proportion of people get
  • Beyond 12 weeks – post-COVID syndrome, or ‘long COVID’
Conducting a short, live poll from the audience to track how many GPs have seen at least one patient with prolonged symptoms beyond 12 weeks after acute COVID, Professor Morgan said the number of GPs in this box is increasing.
 
‘We have GPs in the audience who have a practical and lived experience of people living with these conditions.’
 
The UK COVID Symptom Study app recorded daily symptoms logged by COVID patients. The median duration was 11 days from date of the positive swab test.
 
Professor Morgan notes the significance of the findings at four weeks, when 13% still had some symptoms, and at 12 weeks, when 2.3% of people still had symptoms, classified as long COVID.
 
‘The most reported symptoms were fatigue, headache, anosmia, and lower respiratory symptoms,’ he said. ‘The same study was repeated in the US and Sweden, with similar results.
 
‘I think it’s not a bad estimate of how common patient-reported symptoms are.’
 
Professor Morgan pointed out that there were some flaws in these studies, however, including older people being underrepresented and many people opting out, either due to losing interest, or being too unwell to track their symptoms.
 
‘So, really, that 2.3% of people with long COVID is an estimate rather than an exact figure,’ he said.
 
Another study Professor Morgan cited examined patients with symptoms at 20 weeks post-COVID. The average age was 44 and around 18% had ever been admitted to hospital with their acute illness.
 
‘So this was a low-risk cohort who had long COVID symptoms a long time after their illness, with similar symptoms reported as at the 12 week-mark,’ he said.
 
Blood tests and MRIs from the study revealed indicators of organ impairment in close to 70%. About one-third had cardiac impairment, one-third had signs of lung disease, and 12% kidney disease.
 
‘This is a really remarkable finding,’ Professor Morgan said.
 
‘It’s really quite dramatic in people with long COVID. We need to be aware of the potential for significant rates of organ damage. Multi-organ damage was visible in about a quarter of this population, and remember these were low-risk people.’
 
Examining further international studies, Professor Morgan said to be aware of post-COVID symptoms if caring for someone at home.
 
‘We need to be aware of the amount of care that people might need,’ he said.
 
‘It would be really helpful to understand more about the pathophysiology of long COVID to understand what causes it – there’s been lots of suggestions but no certainty.
 
‘One of the suggestions was that there’s a persistent viremia in people with poor immune systems, but I would have thought that PCR testing would demonstrate this.’
 
Other possibilities include an inflammatory response, the impacts of deconditioning, post-traumatic stress disease, and organ damage.
 
In addition to the importance of GPs being provided with and understanding the details if their patient is admitted to hospital, connecting the patient with their GP upon discharge is also imperative, according to Professor Morgan.
 
‘General practice is well placed to provide this care. We have a lot of trust from our patients
and we’re accessible,’ he said.
 
‘We’ve got information about past medical history, the social context, and we have the expertise to manage conditions based on first principles, even without a strong evidence base for every decision we make.’
 
Diagnostic overshadowing should also be on GPs’ radar.
 
‘If the person comes in with crushing central chest pain, I don’t have to consider acute cardiac ischemia even if the person has long COVID,’ Professor Morgan said. ‘That’s diagnostic overshadowing, and we should be alert to that.’
 
Noting the importance of caring for the individual patient rather than the special features of the disease, Professor Morgan recommends getting as much information as possible.
 
‘Hear the story of what happened to the patient – were they looked after at home? Were they admitted to hospital? Did they need oxygen or ICU? Were they ventilated? And other complications … and of course any comorbidities,’ he said.
 
‘The patient’s ideas, concerns and expectations are also core here. What are they really worried about and what needs to be addressed?’
 
Another short poll asking GPs present on what research questions on the topic they would like to see prioritised.
 
The top response was, ­‘What physical and psychological interventions improve long COVID?’ followed by ‘Which self-care interventions improve?’.
 
‘Those questions are focusing very much on what do we do once they’ve had COVID, and what can we tell them to do to both prevent and treat any ongoing symptoms,’ Professor Morgan said.
 
‘So … questions on the interventions that we might be able to do.
 
‘There will be continued updates and guidelines coming out, and I encourage GPs to keep an eye out for them.’
 
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