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 Webinar, NICE news, the RCGP, and an RCGP e-learning module and an RCGP learning podcast, the BJGP and the NICE guideline.

Prevalence

Evidence is changing rapidly and the Office of National Statistics gives monthly updates on the prevalence of long Covid in the UK

Definitions of long Covid

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

• Ongoing symptomatic Covid-19: Signs/symptoms from four 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 required 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

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 four weeks

Red flags and alternative diagnoses

• Exclude underlying pathology and ‘red flags’ (eg, unexplained chest pain, worsening breathlessness, O₂ sats<96%, new confusion and focal weakness) that require further investigation and treatment, before making a diagnosis of post Covid-19 syndrome
• Hypoxia, abnormal desaturations on mobilisation or cardiac sounding chest pain might be a sign of pericarditis, myocarditis, microvascular angina or venous thromboembolism
• Home pulse oximetry can be helpful in monitoring breathlessness

Investigations to consider in primary care

• Bloods – may include FBC, CRP, U&E, LFTs, Ferritin, BNP, HbA1c and TFTs
• 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 four 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
• 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
• The BJGP suggest treatments for patients with possible mast cell disorder or PoTS
• 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 four 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

Written by Dr Poppy Freeman