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Covid-19 Primary Care Resources


Management of long Covid in primary care



A summary of current guidelines and resources for GPs

 
This information is sourced from the Office of National Statistics (ONS), PHE, the BMJ, a BMJ WebinarNICE news, NICE guideline the RCGP, and an RCGP e-learning module:
 

Prevalence

Evidence is rapidly changing. Recent evidence from the Office of National Statistics on long Covid suggests

  • Over the four-week period ending 6 March 2021, an estimated 1.1 million people in private households in the UK reported experiencing symptoms persisting more than four weeks
  • Prevalence rates of self-reported long Covid were greatest in people aged 35 to 69 years, females, those living in the most deprived areas, those working in health or social care, and those with a pre-existing, activity-limiting health condition

Definitions of long Covid:

The following definitions from NICE should be used for clinical coding:

Ongoing symptomatic Covid-19: Signs/symptoms from 4 weeks up to 12 weeks

Post-Covid-19 syndrome: Signs/symptoms which continue for more than 12 weeks and are not explained by an alternative diagnosis

The term ‘Long Covid’ includes both ongoing symptomatic Covid‑19 and post‑Covid‑19 syndrome

Diagnosing long Covid

  • A positive test for Covid-19 is not a prerequisite for diagnosis
  • Signs and symptoms develop during or after an infection consistent with Covid‑19
  • Severity of initial illness does not help you predict who will have long term symptoms
  • Usually presents with clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any system in the body
  • Symptoms are not explained by an alternative diagnosis
  • Post‑Covid‑19 syndrome may be considered before 12 weeks while the possibility of an alternative underlying disease is also being assessed

Some of the common presentations of Post-Covid-19 syndrome in primary care:

  • Fatigue and post exertional symptom relapse- inability to do anything other than rest is common
  • Breathlessness due to cardiac or respiratory disorders, dysfunctional breathing and dysphonia
  • Tachycardia and autonomic dysfunction including postural tachycardia syndrome (PoTS)
  • GI disturbances such as diarrhoea
  • neurological presentations such as myopathy, neuropathy and cognitive impairment (‘brain fog’)
  • dermatological symptoms such as urticaria and angioedema
  • psychological and psychiatric presentations such as anxiety and depression as primary presentation, or secondary to the adjustment to ongoing effects from an acute illness

PoTS diagnostic criteria: Sustained increase in heart rate of 30 beats per minute (40bpm in teenagers) from lying to standing associated with symptoms of PoTS

Management

NICE advise clinicians to take a comprehensive clinical history and appropriate examination in patients with ongoing symptoms after 4 weeks

Red flags and alternative diagnoses

Investigations to consider in primary care:

  • Bloods – may include FBC, CRP, U&E, LFTs, Ferritin, BNP and TFT
  • ECG – if palpitations or chest pain
  • CXR – if ongoing respiratory symptoms
  • Consider use of a validated cognitive assessment tool if any concerns regarding cognition are raised

Indications for specialist assessment

  • Indications for specialist assessment include clinical concern along with respiratory, cardiac, or neurological symptoms that are new, persistent, or progressive
  • Refer same day if any concerns of an acute thromboembolic event
  • Patients with ongoing pathology across multiple organ systems can be referred to post-Covid MDTs from 4 weeks onwards once other pathology is ruled out
  • Secondary care investigations may include CT, MRI or tilt table

Other guidance for GPs

  • NICE advise GPs to give advice and information on self-management such as setting realistic goals and information about new or continuing symptoms of Covid-19
  • PHE advise patients to discuss local care pathways with their GP and to refer to Your Covid Recovery
  • The RCGP recommends patients are signposted to SIGN patient information
  • Support people in discussions with their employer, school or college eg a phased return
  • Explain to people that it is not known if over-the-counter vitamins and supplements are helpful, harmful or have no effect in the treatment of new or ongoing symptoms of Covid-19
  • Consider social prescribing or referral to social care
  • Children – Consider referral from 4 weeks for specialist advice if ongoing symptomatic Covid‑19 or post‑Covid‑19 syndrome
  • Elderly – Bear in mind that gradual decline, deconditioning, worsening frailty or dementia, loss of interest in eating and drinking can be signs of long Covid
  • Many patients recover spontaneously (if slowly) with holistic support, rest, symptomatic treatment, and gradual increase in activity

See also: 

Fatigue

New onset diabetes

Written by Dr Poppy Freeman

 

Sources

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Published: 11/08/2020
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Published: 07/09/2020
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Published: 30/04/2021
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Published: 30/10/2020
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Published: 05/10/2020
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