The guidance, developed by Imperial College London, is based on the input of 33 clinicians from 14 specialties, 29 of whom had 'lived experience' of long COVID. Eleven members of the panel were GPs.
Published in the BJGP, the guidance aims to help GPs develop confidence in dealing with long COVID. It makes 35 recommendations around diagnosis and management of the condition, which are based on clinical experience.
NICE published guidance on the diagnosis and management of long COVID in December 2020. However, the Imperial researchers said that doctors who had experienced long COVID themselves 'identified that there was a practical gap between best consensus practice in clinical care and the cautious, evidenced-based approach adopted by NICE (itself limited by the paucity of evidence concerning investigation and treatment of this new condition)'.
> Listen to an interview with RCGP clinical lead for clinical policy Dr Gail Allsopp about long COVID in our podcast here
Diagnosing long COVID
The researchers said there is increasing evidence of 'serious long-term sequelae' in patients with long COVID and that health professionals should not assume that patients are suffering from self-limiting post-viral fatigue that can be managed by rehabilitation alone.
GPs should consider long COVID in patients presenting with a wide range of features, not just fatigue and breathlessness, the guidance says. It adds that it is essential that other serious conditions are excluded as part of the diagnosis.
The guidance recommends that GPs carry out an initial face-to-face assessment with patients, which should include a detailed history and examination. Baseline investigations should also be undertaken in primary care.
Further assessment should then be carried out in specialist long COVID clinics. The guidance recommends that these clinics should be set up within integrated care systems and led by a doctor 'well versed in multi-system disorders'.
GPs should play a key role in the multidisciplinary team supporting patients at these clinics, it adds, which should also involve input from mental health specialists, expert physiotherapists and occupational therapists.
Under-18s should have access to a service run by paediatric specialists with knowledge of how presentations and treatments differ from those in adults.
Investigation and treatment
Patients with respiratory symptoms should be considered for a chest X-ray at an early stage. Meanwhile, a referral for cardiac MRI in patients with chest pain should be considered to rule our myopericarditis and microvascular angina.
Indications for further investigation for issues such as myocarditis, postural orthostatic tachycardia syndrome (PoTS) and mast cell disorder include hypoxia/desaturation, chest pain, palpitations, and histamine-related symptoms.
The guidance also makes a number of recommendations about treatment options for specific conditions associated with long-COVID. For example, patients with autonomic dysfunction, including PoTS, could benefit from increased fluids, salts and compression stockings. If these measures are unsuccessful, beta blockers, ivabradine or fludrocortisone could be considered, the guidance says.
Patients with fatigue and symptoms that worsen following activity should be advised about the importance of an initial period of rest following the acute infection and then careful pacing and rest after activity.
Patients should also be supported to 'shift their mental timeline of recovery' and may require a long phased return to work. Regular follow up to monitor progress is also recommended.
Public health crisis
The researchers said: 'In due course, services for investigation, advice, and rehabilitation should be available to all practices. At present, however, the sheer practicalities of managing hundreds of thousands of patients after two waves of COVID-19 mean that GPs need to develop confidence in good practice with long COVID patients, basic investigations, deciding on need for referral or investigation, differential diagnosis, safety netting, empathy and support.
'These statements are a carefully considered and reasonable approach to helping patients until further evidence is available.'
Lead author Professor Brendan Delaney, from Imperial's Institute of Global Health Innovation, said: 'Long COVID is a brewing public health crisis, yet there is no consistent system for how to manage people affected in the UK. There has therefore been an urgent need for clear guidance to help patients access the support they require, and we believe our evidence-led recommendations are a major step towards meeting this need.'