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Managing post-acute issues in COVID patients: What GPs need to know


Evelyn Lewin


20/08/2020 5:23:27 PM

UPDATED: Even people who experienced mild infection may have long-term symptoms.

GP and patient
GPs have been increasingly seeking information on how to best manage ongoing post-acute issues in COVID patients.

UPDATED

Once the most severe phase of COVID-19 infection has passed, many patients experience long-term issues.
 
These patients often describe themselves as ‘long-haulers’ or as having ‘long-COVID’.
 
As the number of Australians diagnosed with COVID-19 has grown, so too has the number of patients with post-acute issues.
 
This has led many GPs to seek information on how to best manage these ongoing concerns. Melbourne-based GP Associate Professor Vicki Kotsirilos, founding Chair of the RACGP Specific Interests Integrative Medicine network, is one of them.
 
‘I actually thought about that last week when I read an article about long-term effects [of COVID-19],’ she told newsGP.
 
‘I thought, “Okay, what will I be advising my patients?”’
 
Associate Professor Kotsirilos says it is ‘totally understandable’ that robust clinical guidelines are not yet in place to help GPs manage patients with long-term sequelae of COVID-19.
 
‘COVID-19 is a new disease and it takes a while for health authorities to prepare clinical, treatment and even practice guidelines,’ she said.
 
‘I don’t think we’ve been slow to provide that information. In fact, if anything, I think the RACGP and health authorities have been excellent.’
 
That said, Associate Professor Kotsirilos says it is imperative GPs are provided with more detailed information when it comes to specific clinical guidelines on helping manage potential long-term effects, such as the hypercoagulable state seen in some patients.
 
‘We clearly do need better and quicker clinical guidelines for us to access,’ she said.
 
‘It is important for GPs to know the best evidence-based treatments in those situations from a long-term perspective.’
 
A new article, published in The BMJ on 11 August, explores management of post-acute issues in COVID-19 patients; though the authors acknowledge there are not yet ‘definitive, evidence-based’ recommendations for management.
 
‘We therefore used a pragmatic approach based on published studies on SARS and MERS, early editorials and consensus based guidance on COVID-19, a living systematic review, early reports of telerehabilitation (support and exercise via video link), and our own clinical experience,’ they wrote.
 
According to the article, which is directed at primary care practitioners, approximately 10% of people remain unwell beyond three weeks after diagnosis with COVID-19.
 
‘Post-acute COVID-19 – “long COVID” – seems to be a multi-system disease, sometimes occurring after a relatively mild acute illness,’ the authors wrote.
 
They say such patients can broadly be divided into those who may have serious sequelae, such as thromboembolic complications, and those with a non-specific clinical picture, mainly characterised by symptoms such as fatigue and breathlessness.
 
The authors define ‘long-COVID’ as extending beyond three weeks from the onset of first symptoms, while ‘chronic-COVID’ is defined as extending beyond 12 weeks.
 
The authors list the symptoms of post-acute COVID-19 as:

  • cough
  • low-grade fever
  • fatigue
  • shortness of breath
  • chest pain
  • headaches
  • neuro-cognitive difficulties
  • muscle pain and weakness
  • gastrointestinal upset
  • rashes
  • metabolic disruption (such as poor control of diabetes)
  • thromboembolic conditions
  • depression and other mental health conditions.
They note that even patients who experienced mild infection may experience long-term symptoms.
 
It is not known why some people’s recovery is prolonged, but the authors say ‘persistent viraemia due to weak or absent antibody response, relapse or reinfection, inflammatory and other immune reactions, deconditioning, and mental factors such as post-traumatic stress’ may all contribute.
 
They say many patients recover spontaneously, if slowly, with holistic support, rest, symptomatic treatment, and gradual increase in activity.
 
When it comes to post-acute effects on various systems, however, the authors also outline a number of specific management strategies.
 
Respiratory
‘A degree of breathlessness is common after acute COVID-19,’ the authors wrote.

On the other hand, severe breathlessness may require urgent referral. The following management principles apply:
 
  • Anaemia should be excluded in patients who are breathless
  • Patients who were not in the intensive care unit (ICU) but who had a significant respiratory illness should have a follow-up chest X-ray at 12 weeks
  • Breathing exercises can be used to assist management of cough (as outlined below)
  • Patients with evidence of lung damage require referral to a respiratory physician and early referral to pulmonary rehabilitation to aid recovery
  • Pulse oximetry may be useful in patients with persistent dyspnoea (as outlined below)
For the breathing exercises, the patient should sit in a supported position, breathing slowly in through the nose and out through the mouth (in a ratio of 1:2) while relaxing the chest and shoulders, allowing the abdomen to rise.
 
‘This technique can be used frequently throughout the day, in 5–10 minute bursts (or longer if helpful),’ the authors wrote.
In terms of pulse oximetry, self-monitoring of oxygen saturations over 3–5 days may be useful in the assessment of patients with persistent dyspnoea in the post-acute phase, especially those in whom baseline saturations are normal and no other cause for dyspnoea is found on thorough evaluation.
 
An exertional desaturation test is recommended in patients as a baseline assessment for those whose resting pulse oximeter reading is 96% or above, but whose symptoms suggest exertional desaturation, such as severe breathlessness on exercise.
 
Such patients should then be challenged by exercise.
 
‘A fall of 3% in the saturation reading on mild exertion is abnormal and requires investigation,’ the authors wrote.

Dr-Vicki-Kotsirilos-article.jpg
Associate Professor Vicki Kotsirilos says clinical guidelines are needed to help GPs manage patients with post-acute symptoms of this infection.

Fatigue
Fatigue is a common complaint following infection with COVID-19.
 
It has also been called ‘the most common and debilitating symptom in [ICU] survivors’.
 
A letter to the editor published in Medical Hypotheses on 27 June highlights the potential for a post-viral syndrome to manifest following COVID-19.
 
‘After the acute SARS episode some patients, many of whom were healthcare workers, went on to develop a chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME)-like illness, which nearly 20 months on prevented them returning to work,’ the authors of the letter wrote.
 
‘We propose that once an acute COVID-19 infection has been overcome, a subgroup of remitted patients are likely to experience long-term adverse effects resembling CFS/ME symptomatology such as persistent fatigue, diffuse myalgia, depressive symptoms, and non-restorative sleep.’
 
The authors of the BMJ article say they found no published evidence on the efficacy of either pharmacological or non-pharmacological interventions on fatigue after COVID-19.

They also say there is ‘much debate and controversy’ about the role of graded exercise in chronic fatigue generally, and in COVID-19 in particular, referencing a recent statement from National Institute for Health and Care Excellence (NICE).
 
‘Pending direct evidence from research studies, we suggest that exercise in such patients should be undertaken cautiously and cut back if the patient develops fever, breathlessness, severe fatigue, or muscle aches,’ the authors wrote.
 
‘Understanding, support, and reassurance from the primary care clinician are a crucial component of management.’
 
Associate Professor Kotsirilos says she would advise patients experiencing fatigue to address lifestyle and behavioural factors.
 
‘Ensuring that they eat well, that they rest, they’re cared for by other people, go to bed early for a good night’s sleep and a graded exercise program,’ she said. ‘It would be just like [management strategies for] patients suffering post-viral fatigue.’
 
Chest pain
This is another common symptom after acute COVID-19, and clinical assessment should follow similar principles to that for any chest pain.
 
‘Where the diagnosis is uncertain, or the patient is acutely unwell, urgent cardiology referral may be needed for specialist assessment and investigations (including echocardiography, computed tomography of the chest, or cardiac magnetic resonance imaging),’ the BMJ authors wrote.
 
Ventricular dysfunction
The authors advise intense cardiovascular exercise ‘must be avoided’ for three months in all patients after myocarditis or pericarditis.
 
Meanwhile, athletes are advised to take 3–6 months of complete rest from cardiovascular training followed by specialist follow-up.
 
Thromboembolism
It is now recognised that COVID-19 can cause a hypercoagulable state with increased risk of thromboembolic events.
 
The authors say many hospitalised patients receive prophylactic anticoagulation.
 
‘Recommendations for anticoagulation after discharge vary, but higher risk patients are typically discharged from hospital with 10 days of extended thromboprophylaxis,’ they wrote.
 
‘If the patient has been diagnosed with a thrombotic episode, anticoagulation and further investigation and monitoring should follow standard guidelines.
 
‘It is not known how long patients remain hypercoagulable following acute COVID-19.’
 
Associate Professor Kotsirilos would like further detailed information for GPs on this topic, including whether the best anticoagulant in this situation is warfarin or another blood thinner, such as low-dose aspirin.
 
‘That is important for GPs to know,’ she said.
 
‘Clinical guidelines are required to help us keep up-to-date with evidence-based appropriate treatments such as the role of blood thinners – when to prescribe them and for how long.’
 
Neurological sequelae
Patients with serious complications such as stroke, seizures or encephalitis should be referred to a neurologist.
 
Meanwhile, non-specific symptoms such as headaches, dizziness and ‘brain fog’ require supportive management and symptom monitoring.
 
Brain fog is a particularly common symptom reported by patients who describe themselves as ‘long-haulers’.
 
Associate Professor Kotsirilos says measures that can help a patient manage fatigue are also applicable for brain fog.
 
‘Brain fog has been seen with other post-viral chronic fatigue syndromes,’ she said.
 
‘With brain fog, it’s all about resting, avoiding the computer, letting the head or brain rest, not returning to work too quickly, exercise especially outdoors for fresh air but gradually.’
 
Other measures include ensuring adequate sleep, reducing stress and eating well.
 
Mental health
‘While a minority of patients may benefit from referral to mental health services, it is important not to pathologise the majority,’ the authors wrote.
 
‘Patient organisations emphasise wellbeing, mindfulness, social connection, self-care (including diet and hydration), peer support, and symptom control.’
 
Associate Professor Kotsirilos agrees these measures can assist with mental health issues. However, she says regular check-ins with a GP and a mental health care plan may also be important if patients are not coping.
 
Holistic management of the patient
Associate Professor Kotsirilos believes GPs are ideally placed to help manage COVID-19 patients with post-acute issues.
 
‘When patients have suffered from COVID-19 infection and are suffering long-term effects like chronic fatigue, GPs are in a great position to validate their symptoms, reassure them, explain to them that it is a new disease, we’re only just coming to understand it, but it is common to get post-viral fatigue, brain fog and other symptoms,’ she said.
 
‘GPs play an important role in helping patients make a full recovery post COVID-19 infection.’
 
She says GPs can also use this opportunity to discuss lifestyle measures, exercise, reducing stress and avoiding harmful substances like excessive alcohol and smoking.
 
The BMJ authors agree primary care practitioners are in an ideal position to ensure ongoing patient care for those with post-acute symptoms of COVID-19.
 
‘From the limited current evidence, we anticipate that many patients whose COVID-19 illness is prolonged will recover without specialist input through a holistic and paced approach,’ they wrote.
 
GPs can also offer their patients much-needed reassurance throughout this process.
 
‘Patients, many of whom were young and fit before their illness, have described being dismissed or treated as hypochondriacs by health professionals,’ the authors wrote.
 
‘In these uncertain times, one key role that the primary care practitioner can play is that of witness, “honouring the story” of the patient whose protracted recovery was unexpected, alarming, and does not make sense.’
 
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Dr Belinda Rowland   19/08/2020 5:29:01 PM

Just a note to say "depressive symptoms" are not included in any diagnostic criteria for ME/CFS, and rates of secondary depression are no different to other chronic conditions like rheumatoid arthritis, so it is misleading to list "depressive symptoms " when providing examples of ME/CFS-like symptomatology.

Also, there is no evidence for efficacy of graded exercise therapy for ME/CFS, and evidence thus far actually suggests likely to do harm and is deemed contraindicated by many knowledgeable clinicians and researchers at this stage. It has been removed from CDC guidelines, and NICE guidelines include a precaution also. There is a Cochrane review amendment/correction in the works as far as I am aware also.


Dr Jennifer Altermatt   20/08/2020 7:39:51 AM

Thanks to Prof Kotsirilos for an informative and well balanced article providing great assistance to me in a checklist to remember to ask my post Covid patients!


Dr Carolyn Cheng - Ling Ee   20/08/2020 9:20:05 PM

Thank you for highlighting this really important issue and the important role that GPs play in providing whole-person, supportive care of people experiencing post-COVID symptoms! No doubt this will continue to be a growing and persistent problem.