NICE guideline on long covid – BMJ 2020 Dec 23

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Long COVID: A Primer for Family Physicians – Editorial -AFP 2020 December

The term long COVID was coined by online communities of patients who felt dismissed by their physicians as overreacting to “mild” illness.5 However, evidence is accumulating that long COVID is a distinct syndrome, perhaps due to a dysfunctional immune-inflammatory response, that can affect people who were never hospitalized and may occur without a history of a polymerase chain reaction test positive for COVID-19. 4,6 There are no official guidelines for the management of long COVID, but a recent review has highlighted some important principles,4 which we will briefly summarize.

The key task of the family physician is to distinguish patients with life-threatening or serious post-COVID complications from those with less concerning symptoms. Serious complications include pulmonary embolus, heart failure, stroke, myocardial infarction, lung fibrosis, neurologic derangement, and severe deterioration in mental health. Patients presenting with nonserious symptoms benefit from support and reassurance through a natural process of convalescence.7-9 Evaluation for alternative diagnoses (e.g., deteriorating comorbidities, infection, endocrine disturbance) is vital because not all illness in a patient recovering from COVID-19 is caused by postacute COVID-19

(AFP Editorial)

Long Covid

From NICE

The covid-19 pandemic has killed over 1.6 million people worldwide,1 caused the worst healthcare crisis of this century, and put a huge dent in our economies. The magnitude of the population still struggling with symptoms four weeks after their acute illness—commonly called “long covid”—is becoming obvious and demands urgent prioritisation to prevent a further blow to health systems and the healthcare workforce.

Long covid is thought to occur in approximately 10% of people infected,23 so there are likely more than 5 million people affected globally. The National Institute for Health and Care Excellence (NICE), the Scottish Intercollegiate Guidelines Network, and the Royal College of General Practitioners have developed a rapid guideline for managing the long term effects of covid-194 to assist long covid services being set up in the NHS5 and elsewhere. A lack of systematic research means that the current guideline is necessarily preliminary, but it will be updated regularly as new evidence emerges—becoming a “living guideline.” This approach is essential as the current guideline lacks important detail, including a comprehensive list of organ complications seen in patients with long covid, the investigations required, and specific interventions for these complications.

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Management of post-acute covid-19 in primary care – BMJ 2020 August  

What you need to know

  • Management of covid-19 after the first three weeks is currently based on limited evidence

  • Approximately 10% of people experience prolonged illness after covid-19

  • Many such patients recover spontaneously (if slowly) with holistic support, rest, symptomatic treatment, and gradual increase in activity

  • 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

 

 

Why are some people affected?

It is not known why some people’s recovery is prolonged. Persistent viraemia due to weak or absent antibody response,11 relapse or reinfection,12 inflammatory and other immune reactions,1314 deconditioning,2 and mental factors such as post-traumatic stress1516 may all contribute. Long term respiratory, musculoskeletal, and neuropsychiatric sequelae have been described for other coronaviruses (SARS and MERS),171819202122 and these have pathophysiological parallels with post-acute covid-19.23

What are the symptoms?

Post-acute covid-19 symptoms vary widely. Even so-called mild covid-19 may be associated with long term symptoms, most commonly cough, low grade fever, and fatigue, all of which may relapse and remit.47 Other reported symptoms include shortness of breath, chest pain, headaches, neurocognitive difficulties, muscle pains and weakness, gastrointestinal upset, rashes, metabolic disruption (such as poor control of diabetes), thromboembolic conditions, and depression and other mental health conditions.424 Skin rashes can take many forms including vesicular, maculopapular, urticarial, or chilblain-like lesions on the extremities (so called covid toe).25 There seems to be no need to refer or investigate these if the patient is otherwise well.

What tests are required?

Blood tests should be ordered selectively and for specific clinical indications after a careful history and examination (see infographic); the patient may not need any. Anaemia should be excluded in the breathless patient. Lymphopenia is a feature of severe, acute covid-19. Elevated biomarkers may include C reactive protein (for example, acute infection), white cell count (infection or inflammatory response), natriuretic peptides (for example, heart failure), ferritin (inflammation and continuing prothrombotic state), troponin (acute coronary syndrome or myocarditis) and D-dimer (thromboembolic disease). Troponin and D-dimer tests may be falsely positive, but a negative result can reduce clinical uncertainty. Further research is likely to refine the indications for, and interpretation of, diagnostic and monitoring tests in follow-up of covid-19.


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