Infectious Disease

The complexity of managing long COVID

December 08, 2023

4 min read

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Key takeaways:

  • The wide range of symptoms associated with long COVID makes diagnosing and managing long COVID difficult.
  • Research on effective treatments for long COVID, like antivirals used to fight the virus, is underway.

Long COVID can be difficult for primary care physicians to manage, but they are in a unique position to provide the best care for the condition, according to experts.

The latest data from the CDC revealed that an estimated 6.9% of adults and 1.3% of children in the United States have experienced long COVID, a condition in which COVID-19-related symptoms linger beyond 3 weeks, after the acute phase of the infection has passed. Previous research has indicated that, after recovery from the acute phase of the disease, long COVID-related conditions may persist for as long as 2 years.

The mechanisms underlying long COVID remain largely unknown, but researchers have traced symptoms to a lingering infection of the SARS-CoV-2 virus in the gut, which lowers a patient’s serotonin levels.

Kin Wah Fung, MD, a staff scientist at the National Library of Medicine’s Lister Hill National Center for Biomedical Communications, told Healio that “even though the COVID-19 pandemic is waning,” many PCPs are still seeing patients struggling with outcomes related to the SARS-CoV-2 virus.

“Millions of patients are still suffering from the mysterious and sometimes debilitating condition of long COVID,” Fung said.


Long COVID comes with “a wide range of symptoms” that can affect daily life, according to Teresa L. Lovins, MD, FAAFP, a member of the board of directors of the American Academy of Family Physicians. Previous research has indicated that the most common symptoms include headache, fatigue and brain fog, but many others can also be tied to the condition.

Anthony Ognjan, DO, a board-certified osteopathic physician specializing in infectious diseases, said he has firsthand experience with “what could be considered long COVID symptoms.”

“I had chronic dizzy spells that came out of nowhere. I have fatigue, insomnia and other symptoms that I have also seen from patients,” said Ognjan, who is also a member of the American Osteopathic Association and Michigan Osteopathic Association.

Aside from the most prevalent symptoms, Ognjan said he has seen patients present with heart palpitations, chest pain, anxiety and sleep troubles.

“There are so many symptoms that are intertwined from medical to psychological and there is so much research that still needs to be done,” he said.

Lovins said the wide variety and inconsistent nature of long COVID symptoms is one part of what makes diagnosing and managing the condition complicated.

“Because the symptoms are so wide-ranging, diagnosing long COVID can be difficult and it can be hard to differentiate them from other conditions or illnesses,” Lovins said.

However, as PCPs are often “the main source of care for patients who are managing chronic conditions,” Lovins said, “they are in a unique position to provide and coordinate care for vulnerable patients with long COVID.”

Managing long COVID

Getting the COVID-19 vaccine “remains the best way to prevent COVID-19, and in turn, the possibility of developing long COVID,” Lovins said. But once the patient already has the condition, it can be difficult for PCPs to effectively manage.

“I have seen long COVID patients, and I am dealing with one case in particular that is really complicated,” Lovins said. “The patient has been left with mental fog, mood disorder, blood pressure and heart rate issues, trouble exercising, body and joint pains, stomach symptoms and renal insufficiency. She went from being a very active person doing spin classes two times per day to now being on disability.”

Her patient has tried various treatments, Lovins said — pulmonary rehab, multiple medication adjustments and cognitive behavioral therapy — highlighting the difficulty of managing the condition.

“There’s no one-size-fits-all approach to treating long COVID, but family physicians can help manage long-COVID symptoms to improve a patient’s quality of life,” Lovins said. “We work with patients to develop a comprehensive management plan based on symptoms, any existing chronic physical and mental health needs, treatment goals and individual circumstances.”

Treatment options

Because people have been affected by the virus in different ways and varying degrees, “it’s difficult to have one effective treatment solution,” Ognjan said.

“In the same way that people who contracted COVID ranged from mild to severe symptoms, the side effects of long COVID also manifested its way in many contrasting elements,” he said. “As physicians, there isn’t simply one type of medication that treats people, because someone who has brain fog is going to need something differently than someone with fatigue or headaches. It will also be different for someone who started asymptomatic when they first had COVID, but later on are beginning to feel unexpected side effects.”

However, efforts are already underway to research possible treatment options.

Last summer, the NIH announced that it launched phase 2 clinical trials to evaluate at least four potential long COVID treatments. Other independent research has indicated that exercise-based rehabilitation interventions may help improve quality of life and functional exercise capacity for patients with long COVID and that the antiviral nirmatrelvir, which is part of Paxlovid (Pfizer), may reduce the risk for the condition.

Fung and colleagues published a cohort study in JAMA Internal Medicine evaluating the effect nirmatrelvir and Lagevrio (molnupiravir, Merck) may have on long COVID. The study, which included 2 million patients aged at least 65 years with COVID-19, revealed that the antivirals were both linked to “small but statistically significant” reductions in the incidence of long COVID.

“Persistence of SARS-CoV-2 infection is one of the possible mechanisms in the cause of long COVID. Since nirmatrelvir and molnupiravir stop viral replication, there is a distinct possibility that they might help to treat long COVID,” Fung said. “The potential protection against long COVID could be an additional reason to persuade patients who have the indications [for treatment] but are reluctant to receive treatment.”

Until more solid research cements a type of medication as a treatment for long COVID, Lovins said PCPs can recommend techniques or treatments that can be used at home such as olfactory training to regain one’s sense of smell and taste or breathing exercises for lung function improvement.

Although Lovins said most patients gradually see improvement in their symptoms over time, “for now, the long-term prognosis of long COVID is unclear.”

“Long COVID is still a relatively new condition, and experts are working to understand more about who experiences it and the long-term effects,” Lovins said. “Continued research to understand the exact causes of long COVID and related symptoms will determine whether a cure is possible, but as we learn more, physicians will continue to be better equipped to help patients manage symptoms.”


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