The Office for National Statistics (ONS) data show that as of 31st October, an estimated 1.2 million people (1.9% of the population) reported having long COVID. About a third of those still had ongoing symptoms at least a year after their initial infection.
The vast number of patients seeking help for long COVID is adding immense pressure to already stretched primary care services. GPs play a key role in the multidisciplinary team caring for patients with long COVID, including in long COVID clinics. They are working hard to support patients but recognising and managing the symptoms of long COVID is difficult, especially given the limited clinical experience and evidence for dealing with such a new condition.
GPs need guidance, training and resources to be able to offer patients the help they need.
How is long COVID defined?
‘Long COVID’ is the common term used by patients and clinicians to mean signs and symptoms that continue or develop after acute COVID‑19.
According to the COVID-19 rapid guideline: managing the long-term effects of COVID-19, developed by the National Institute for Health and Care Excellence (NICE) in collaboration with the Royal College of GPs (RCGP) and Scottish Intercollegiate Guidelines Network (SIGN), the relevant clinical case definitions are:
- “Ongoing symptomatic COVID-19 – signs and symptoms of COVID‑19 from 4 weeks up to 12 weeks.”
- “Post-COVID-19 syndrome – signs and symptoms that develop during or after an infection consistent with COVID‑19, continue for more than 12 weeks and are not explained by an alternative diagnosis. It usually presents with clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any system in the body. Post‑COVID‑19 syndrome may be considered before 12 weeks while the possibility of an alternative underlying disease is also being assessed.”
GPs should ensure they use the correct clinical codes in patients’ records to support diagnosis, management and referral of patients with long COVID.
What are the symptoms?
Long COVID is unpredictable, with widely varying symptoms and a relapsing-remitting disease course. The most common symptoms are fatigue (54%), shortness of breath (36%), loss of smell (35%) and difficulty concentrating (28%) but numerous others are described.
Many GPs also report that patients with long COVID have poor mental health, often suffering from anxiety and depression as a result of their ongoing condition and its daily impact on their lives. Managing patients’ expectations early on and informing them about long COVID may be an important step in helping them cope with long-lasting symptoms.
What should GPs do for patients with long COVID?
The NICE guidelines offer consensus recommendations for management of (suspected) long COVID. Key aspects for GPs to follow include:
- A comprehensive clinical history and appropriate examination to assess physical, cognitive, psychological and psychiatric symptoms, as well as functional abilities.
- Tailored tests and investigations to rule out acute or life threatening complications and find out if symptoms are likely due to long COVID or an unrelated diagnosis.
- Refer people to relevant acute services if they have signs or symptoms that could be caused by an acute or life threatening complication, including (but not limited to):
- hypoxaemia or oxygen desaturation on exercise
- signs of severe lung disease
- cardiac chest pain
- paediatric inflammatory multisystem syndrome – temporally associated with SARS-CoV-2 (PIMS-TS).
- Consider referring people to an appropriate service, such as an integrated multidisciplinary assessment service, any time from 4 weeks after the start of acute COVID-19.
- Do not exclude people from referral based on the absence of a positive SARS‑CoV‑2 test (PCR, antigen or antibody) as long as the case definition criteria are met.
- Use shared decision making to agree what support, rehabilitation and monitoring the person needs.
- Give advice and information on self-management and other sources of support.
Unfortunately, the guidelines panel found no evidence for specific treatments for long COVID although some common symptoms can be managed with established treatments.
Further practical recommendations
The NICE guidance has been described as cautious due to the lack of evidence. GPs may require additional practical recommendations. To meet this need, a panel of doctors, including GPs, developed Recommendations for the recognition, diagnosis, and management of long COVID: a Delphi study.
In the absence of conclusive research, this expert guide is based on emerging clinical experience. The authors wrote that “the statements go further than NICE in many areas, particularly in the need to investigate potential cardiac conditions, dysautonomia, and immune dysfunction.”
GPs wanting to better understand how to help their patients with long COVID may also find the following resources useful:
For GPs from RCGP:
- Long term effects of COVID-19 and Post-COVID-19 syndrome: eLearning module.
- Long COVID eLearning Podcast.
- Post COVID-19 Syndrome (“Long Covid”) Where are we now?: webinar.
Top tips for GPs:
- Your COVID recovery: An NHS England resource.
- Long-term effects of COVID-19 (long COVID): An NHS inform website for patients in Scotland.
Please contact us at Medical Defense Society if you are a GP needing medico-legal advice or support related to caring for patients with long COVID.