Thirty-five concise and practical suggestions were developed using a rigorous consensus approach (the Delphi process) to aid in the organisation of clinics, as well as the diagnosis and treatment of patients with protracted COVID.

The phrase 'post-COVID-19 condition' refers to a complicated, multisystem disease that occurs immediately or sometime after an acute COVID-19 infection, regardless of severity. Patient groups acquired the phrases 'long COVID' (UK) and 'long-haulers' (US) when they gathered to compare their experiences. While most of the attention and lobbying has focused on the phrase 'extended COVID,' the World Health Organisation (WHO) and SNOMED International have classified the disease as a 'post-COVID-19 condition'.

The sickness is often unexpected, relapsing-remitting, and major accompanying problems frequently manifest themselves weeks to months into the disease course. It is thus recommended to have a high index of suspicion and a low threshold for referral to secondary care experts or doctor-led extended COVID clinics with diagnostic capability, depending on local availability.

Long COVID in India

The second wave of COVID-19 was much more contagious than the first wave, according to research conducted by Apollo Hospitals. The research shows that the number of patients reported for long-term COVID and post-COVID problems after the second wave of the pandemic is four times than what was recorded last year.

Long COVID is a condition in which individuals who have recovered from COVID-19 continue to show symptoms much longer than is typically anticipated.

According to the research,

"The variation of concern this time was different with novel symptoms including high-grade fever, diarrhoea, severe lung infection followed by lengthy COVID syndrome and post-COVID consequences like decreasing oxygen levels and lung fibrosis that emerged even after 8 weeks or more after testing positive."

Clinical approaches and advice for extended COVID, which is estimated to impact 10% of individuals diagnosed with COVID-19, are urgently needed. Without definitive data to guide clinical treatment, 'expert physician–patients' (that is, physicians with extensive COVID experience and those engaged in fledgling clinics) provide professional competence. Multidisciplinary clinics supervised by physicians are necessary since severe cardiovascular, neurocognitive, pulmonary, and immunological consequences may appear with merely non-specific symptoms.

Now, to help with managing long-COVID, new guidelines have been drafted. To collect, organise, and distribute this information, rigorous consensus-based techniques have been utilised to provide recommendations for best practices in the identification, investigation, and treatment of protracted COVID. These guidelines are designed to assist generalist physicians who are medically supervising a community-based long-term COVID clinic and who has access to specialist referrals if necessary.

Final list of recommendations

The final list comprises 35 recommendations: six relating to clinic organisation, 13 to the diagnosis of the underlying disorder and 16 to management.

1. Consider long COVID in patients with a clinical diagnosis of COVID-19 as per WHO criteria or test-positive, have a history with new or fluctuating symptoms including but not limited to breathlessness, chest pain, palpitations, inappropriate tachycardia, wheeze, stridor, urticaria, abdominal pain, diarrhoea, arthralgia, neuralgia, dysphonia, fatigue including neurocognitive fatigue, cognitive impairment, prolonged pyrexia, and neuropathy occurring beyond 4 weeks of initial COVID-19 (strongly agree 19, 58%; agree 11, 33%; neither agree nor disagree = 0, 0%; disagree = 2, 6%; strongly disagree = 1, 3%).
2. Multi-specialty long-COVID clinics should be led by a doctor with cross-specialty knowledge and experience of managing this condition (strongly agree = 29, 88%; agree = 2, 6%; neither agree nor disagree = 1, 3%; disagree = 0, 0%; strongly disagree = 1, 3%).
3. Consider individualised investigations, management, and rehabilitation planning via a multi-speciality long COVID assessment service as local services allow. Prioritise physician-led medical assessments and diagnostics initially, and consider allied health professionals including physiotherapy and occupational therapist input as adjuncts (strongly agree = 23, 70%; agree = 8, 24%; neither agree nor disagree = 1, 3%; disagree = 1, 3%; strongly disagree = 0, 0%).
4. It is inappropriate for long COVID clinics to be led by mental health specialists, for example, IAPT [Improved Access to Psychological Therapy], clinical or health psychologist. They may be useful in supporting the multi-specialty team but do not have the expertise to investigate and manage potential organ damage (strongly agree = 27, 82%; agree = 5, 15%; neither agree nor disagree = 1, 3%; disagree = 0, 0%; strongly disagree = 0, 0%).
5. All under-18-year-olds need access to similar services run by paediatric specialists with knowledge of how presentations and treatments differ for adults and with close liaison with school (strongly agree = 26, 79%; agree = 7, 21%; neither agree nor disagree = 0, 0%; disagree = 0, 0%; strongly disagree = 0, 0%).
6. Patients with comorbid mental health difficulties should have equal access to medical care as a patient without mental health difficulties and should not be triaged away from services (strongly agree = 28, 85%; agree = 5, 15%; neither agree nor disagree = 0, 0%; disagree = 0, 0%; strongly disagree = 0, 0%).

General approach

1. In someone with long COVID, symptoms of possible non-COVID-19-related issues should be investigated and referred as per local guidelines. Long COVID alone is not a sufficient diagnosis unless other causes have been excluded (strongly agree = 21, 64%; agree = 8, 24%; neither agree nor disagree = 2, 6%; disagree = 1, 3%; strongly disagree = 1, 3%).
2. Carry out a face-to-face assessment including a thorough history and examination, consider other non-COVID-19-related diagnoses, and measure full blood count, renal function, C-reactive protein, liver function test, thyroid function, haemoglobin A1c (HbA1c), vitamin D, magnesium,a B12, folate, ferritin, and bone studies (strongly agree = 24, 73%; agree = 9, 27%; neither agree nor disagree = 0, 0%; disagree = 0, 0%; strongly disagree = 0, 0%).

Respiratory

1. In those with respiratory symptoms, consider chest X-ray at an early stage. Be aware that a normal appearance does not exclude respiratory pathology (strongly agree = 27, 82%; agree = 4, 12%; neither agree nor disagree = 1, 3%; disagree = 1, 3%; strongly disagree = 0, 0%).
2. Be aware that simple spirometry may be normal but patients may have diffusion defects indicative of scarring, chronic pulmonary embolisms, or microthrombi. Consider referral to respiratory for full lung function testing (strongly agree = 23, 70%; agree = 10, 30%; neither agree nor disagree = 0, 0%; disagree = 0, 0%; strongly disagree = 0, 0%).
3. Measure oxygen saturation at rest and after an age-appropriate brief exercise test in people with breathlessness and refer for investigation if hypoxaemic or if any desaturation on exercise (strongly agree = 17, 52%; agree = 14, 42%; neither agree nor disagree = 2, 6%; disagree = 0, 0%; strongly disagree = 0, 0%).

Cardiac

1. Consider the possibility of a cardiac cause of breathlessness (strongly agree = 27, 82%; agree = 5, 15%; neither agree nor disagree = 0, 0%; disagree = 0, 0%; strongly disagree = 1, 3%).
2. Be aware that a normal D-dimer may not exclude thromboembolism, especially in a chronic setting, and referral for investigation is therefore indicated if there is a clinical suspicion of pulmonary emboli. Additionally, be mindful that thromboembolism may occur at any stage during the disease course (strongly agree = 26, 79%; agree = 6, 18%; neither agree nor disagree = 1, 3%; disagree = 0, 0%; strongly disagree = 0, 0%).
3. In patients with inappropriate tachycardia and/or chest pain, carry out electrocardiogram, troponin, Holter monitoring, and echocardiography. Be aware that myocarditis and pericarditis cannot be excluded on echocardiography alone (strongly agree = 22, 67%; agree = 8, 24%; neither agree nor disagree = 2, 6%; disagree = 1, 3%; strongly disagree = 0, 0%).
4. In patients with chest pain, consider a referral to cardiology as cardiac magnetic resonance imaging may be indicated in a normal echo to rule out myopericarditis and microvascular angina (strongly agree = 25, 76%; agree = 6, 18%; neither agree nor disagree = 1, 3%; disagree = 1, 3%; strongly disagree = 0, 0%).
5. In patients with palpitations and/or tachycardia, consider autonomic dysfunction (strongly agree = 25, 76%; agree = 7, 21%; neither agree nor disagree = 0, 0%; disagree = 0, 0%; strongly disagree = 1, 3%).

Others

1. In patients with urticaria, conjunctivitis, wheeze, inappropriate tachycardia, palpitations, shortness of breath, heartburn, abdominal cramps or bloating, diarrhoea, sleep disturbance, or neurocognitive fatigue,9 consider mast cell disorder (strongly agree = 15, 46%; agree = 14, 42%; neither agree nor disagree = 4, 12%; disagree = 0, 0%; strongly disagree = 0, 0%).
2. In patients with cognitive difficulties sufficient to interfere with work or social functioning, consider neurocognitive assessment (strongly agree = 23, 70%; agree = 9, 27%; neither agree nor disagree = 0, 0%; disagree = 1, 3%; strongly disagree = 0, 0%).
3. In patients with joint swelling and arthralgia, consider a diagnosis of reactive arthritis or new connective tissue disease and investigate and refer as appropriate (strongly agree = 20, 61%; agree = 12, 36%; neither agree nor disagree = 1, 3%; disagree = 0, 0%; strongly disagree = 0, 0%).
4. For patients with fatigue and worsening symptoms hours to days following an activity, emphasise the importance of an initial phase of convalescence followed by careful pacing and rest (strongly agree = 27, 82%; agree = 6, 18%; neither agree nor disagree = 0, 0%; disagree = 0, 0%; strongly disagree = 0, 0%).
5. Support patients in shifting their mental timeline of recovery to reflect the likely prolonged course, with a possibly long phased return to work (strongly agree = 24, 73%; agree = 9, 27%; neither agree nor disagree = 0, 0%; disagree = 0, 0%; strongly disagree = 0, 0%).
6. Further support patients with signposting to patient resources. Applicable resources may include: management of post-exertional symptom exacerbation, activity pacing, acupuncture, diagnosis-specific management as relevant (strongly agree = 14, 42%; agree = 16, 49%; neither agree nor disagree = 1, 3%; disagree = 2, 6%; strongly disagree = 0, 0%).
7. Provide patients with signposting to social prescribing, sickness certification, and financial advice. Discuss with the patient whether sickness certification will state long COVID as diagnosis (strongly agree = 26, 79%; agree = 6, 18%; neither agree nor disagree = 1, 3%; disagree = 0, 0%; strongly disagree = 0, 0%).
8. Clinicians should ensure that the occupational status of patients with long COVID is recorded (in/out of work, part-/full-time, student) (strongly agree = 25, 76%; agree = 8, 24%; neither agree nor disagree = 0, 0%; disagree = 0, 0%; strongly disagree = 0, 0%).
9. Follow patients up regularly to monitor progress from a full biopsychosocial and occupational perspective (strongly agree = 19, 58%; agree = 13, 39%; neither agree nor disagree = 1, 3%; disagree = 0, 0%; strongly disagree = 0, 0%).
10. Encourage reporting of new symptoms (expected) and expectation of waxing–waning course (strongly agree = 25, 76%; agree = 8, 24%; neither agree nor disagree = 0, 0%; disagree = 0, 0%; strongly disagree = 0, 0%).
11. Consider contributing patient data to research on long COVID, using the WHO Case Report Form or similar10(strongly agree = 22, 67%; agree = 9, 27%; neither agree nor disagree = 2, 6%; disagree = 0, 0%; strongly disagree = 0, 0%).
12. Patients with cardiac symptoms should be advised to limit their heart rate to 60% of maximum (usually around 100–110 beats per minute) and investigated with at least electrocardiogram and echocardiogram before taking up exercise. Supervised exercise testing should be considered for this patient group as they may have perimyocarditis and exercise carries risk of arrhythmia and worsening cardiac function11 (strongly agree = 16, 49%; agree = 14, 42%; neither agree nor disagree = 2, 6%; disagree = 1, 3%; strongly disagree = 0, 0%).
13. For autonomic dysfunction including postural orthostatic tachycardia syndrome (PoTs), consider first increased fluids, salts, compression hosiery, and specific rehabilitation12 (strongly agree = 18, 55%; agree = 13, 39%; neither agree nor disagree = 2, 6%; disagree = 0, 0%; strongly disagree = 0, 0%).
14. If PoTS and no or inadequate response to non-pharmacological therapy consider beta-blocker, ivabradine, or fludrocortisone (with blood pressure and response monitoring) (strongly agree = 18, 55%; agree = 13, 39%; neither agree nor disagree = 1, 3%; disagree = 1, 3%; strongly disagree = 0, 0%).
15. In patients with possible mast cell disorder, consider a 1-month trial of initial medical treatment and dietary advice. Higher than standard doses of antihistamines are commonly used for this indication. If partial effect, consider adding second-level treatment such as montelukast, as well as referral to allergy or immunology specialists13,14 (strongly agree = 17, 52%; agree = 14, 42%; neither agree nor disagree = 2, 6%; disagree = 0, 0%; strongly disagree = 0, 0%).
16. Be aware that adverse drug reactions are more common in patients with mast cell disorder, for example, to beta-lactam antibiotics, non-steriodal anti-inflammatory drugs, codeine, morphine, or buprenorphine (strongly agree = 17, 52%; agree = 13, 39%; neither agree nor disagree = 3, 9%; disagree = 0, 0%; strongly disagree = 0, 0%).
17. For breathing pattern disorder, consider specialist physiotherapy and/or using alternative therapies such as pranayama breathing and meditation (strongly agree = 12, 36%; agree = 14, 42%; neither agree nor disagree = 4, 12%; disagree = 3, 9%; strongly disagree = 0, 0%).
18. In patients expressing distress, significant low mood, anxiety, or symptoms of post-traumatic stress disorder, consider mental health assessment (strongly agree = 20, 61%; agree = 13, 39%; neither agree nor disagree = 0, 0%; disagree = 0, 0%; strongly disagree = 0, 0%).
19. Over-the-counter supplementation is common, including vitamin C, D, niacin (nicotinic acid), and quercetin. Be aware of significant drug interactions, such as with niacin or quercetin (strongly agree = 21, 64%; agree = 10, 30%; neither agree nor disagree = 1, 3%; disagree = 0, 0%; strongly disagree = 1, 3%).

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author is a practising super specialist from New Delhi.