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Covid-19 Primary Care Resources


Management of long Covid in primary care



A summary of current guidelines on symptoms, criteria for diagnosis and an approach to management

 

This information is sourced from PHE, the BMJ, a BMJ WebinarNICE news, NICE guideline and the RCGP:

Estimated prevalence of long Covid:

  • PHE stated in September 2020 that around 10% of mild Covid-19 cases who were not admitted to hospital have reported symptoms lasting more than 4 weeks
  • NICE estimated in October 2020 there could be as many as 60,000 people in the UK who probably have Long Covid

Definitions of long Covid:

The BMJ:

  • Post-acute Covid-19 or long Covid extends beyond three weeks from onset of first symptoms
  • Chronic Covid-19 extends beyond 12 weeks

NICE:

Acute Covid-19: Signs/symptoms for up to 4 weeks

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
  • Usually presents with clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any system in the body
  • Symptoms 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

Symptoms/health sequelae of ongoing symptomatic Covid-19 and post-Covid-19 syndrome include:

Respiratory: Breathlessness/ cough/ shortness of breath, lung inflammation and fibrosis, and pulmonary vascular disease

Cardiovascular: Chest tightness or pain/ palpitations/ acute myocarditis, heart failure and Postural Tachycardia syndrome (PoTs)

Generalised: Fatigue/ fever/ pain/ lymphadenopathy

Neurological: Cognitive impairment (‘brain fog’)/ headache/ sleep disturbance/ peripheral neuropathy symptoms (pins and needles and numbness)/ dizziness/ delirium (in older populations)

Gastrointestinal: Abdominal pain/ nausea/ diarrhoea/ anorexia and reduced appetite (in older populations)/ liver and kidney dysfunction

MSKJoint/ muscle pain/ multisystem inflammatory syndrome, Guillain-Barre syndrome, or neuralgic amyotrophy

Psychological/psychiatric: Symptoms of depression/anxiety

ENT: Tinnitus/ earache/ sore throat/ dizziness/ Loss of taste and/or smell

DermatologicalSkin rashes

Haematological: Clotting disorders and thrombosis

Endocrine: Worsening diabetic control or worsening of underlying metabolic disease

Management – key points:

  • NICE advise clinicians to take a comprehensive clinical history and appropriate examination in patients with ongoing symptoms after 4 weeks
  • The BMJ advise to exclude underlying pathology and “red flags” that require further investigation and treatment, before a diagnosis of post Covid-19 syndrome is made
  • Home pulse oximetry can be helpful in monitoring breathlessness
  • Indications for specialist assessment include clinical concern along with respiratory, cardiac, or neurological symptoms that are new, persistent, or progressive
  • 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
  • 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
  • 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

” It [Long Covid recovery] should be a story of gradual improvement, and if it’s not, consider referring,” 

” GPs have the clinical skills to manage these people, such as listening to the patient, documenting what the symptoms are, how they change and how they fluctuate, and being alert to symptoms that might suggest they need referring.”

                             Trisha Greenhalgh, professor of primary care health sciences

See also: Fatigue