Long covid—an update for primary care
BMJ 2022; 378 doi: https://doi.org/10.1136/bmj-2022-072117 (Published 22 September 2022) Cite this as: BMJ 2022;378:e072117
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Dear Editor
The update reminds us that alternative diagnoses should be considered in patients presenting with long covid symptoms. I suggest that screening for coeliac disease should be added to the list of conditions to look for. Coeliac disease occurs in more than 1% of the population, with many more cases undiagnosed. Typical symptoms of fatigue and GI problems are the similar to those of long covid.
Screening for coeliac disease with anti-TTG antibodies is recommended for anyone with unexplained persistent fatigue or GI symptoms. It is a simple test to do. Ideally test for total IGA too in case of IGA deficiency. Screening can easily be done for patients presenting with fatigue or GI symtpoms after covid. Screening should also be considered for patients with the chronic fatigue syndrome (CFS).
1. Ashton J, Smith R, Smith T, Beattie R. Investigating Coeliac Disease in Adults. BMJ 2020:369:m2176
Competing interests: No competing interests
Dear Editor,
I think it must be a fraught task, writing about Long Covid. Its list of symptoms are huge and we don't really know how it arises. I often feel inadequate faced with patients distressed by their Long Covid symptoms.
I was bothered by the lack of any mention by the authors of a functional element to Long Covid. It seemed a huge omission to me. Many of the complaints we see in primary care are of a functional nature primarily and there is often a large functional component to physical illness like COPD and asthma, heart disease and musculoskeletal pains. How can we start to help people who suffer functional symptoms if there is a taboo about mentioning it? People with functional symptoms are suffering in the same way as those with physical symptoms and if we are to destygmatise this area of medicine then authors as important and respected as Greenhalgh et al should acknowledge their existence. It would be extraordinary if many people sufferring Long Covid did not have a functional element to their presentations. Concentrating on physical tests and bodily mechanisms wholly risks missing this component.
Competing interests: No competing interests
Dear Editor
It is disappointing that the profound effect of covid-19 on women’s reproductive hormones is largely unacknowledged in the recent article ‘Long covid – an update for primary care’.
Sex-specific differences in the immune response are believed to underlie the lower mortality rate in premenopausal women from acute covid-19 infection. Postmenopausal women are at higher risk of death, unless they take hormone replacement therapy (HRT) which reduces mortality by two thirds compared with non-HRT users [1]. However, women are more likely to develop long covid, and the risk is highest in middle-aged women who account for around 40% of all patients with long covid [2-4].
Menstrual cycle changes in women with long covid are common. In an unselected cohort, one third of women reported a persistent change in their periods [5]. Furthermore, many long covid symptoms such as fatigue, brain fog, sleep disturbance, palpitations, and joint pains, are also common in the perimenopause. In ‘Table 1’, the authors list a number of symptoms alongside suggested investigations and management strategies. There is no mention that virus-induced sex hormone deficiency may also underlie many of these symptoms. If health care professionals are not prompted to consider the effects of covid-19 on women’s hormones, the diagnosis of perimenopause will be missed. In one survey, despite 70% of women with long covid thinking that their symptoms might be hormone-related, 84% had not been asked about, or offered treatment for, the perimenopause [6]. The authors state that ‘holistic management is key’, so it is important to highlight that post-covid hormonal perturbations are a major barrier to recovery, if not addressed.
In my experience, a management approach that focusses solely on rehabilitation has been of limited benefit. Given the unique challenge of treating a new disease, with no evidence base on which to make treatment recommendations, my colleagues and I have adopted a consistent approach to long covid management based on our collective, clinical experience and informed by our patients’ feedback [7]. To our knowledge, this is the only long covid guideline that includes information and practical advice about managing perimenopausal symptoms in long covid patients, and recommending the use of HRT as an adjunct to therapy.
HRT is not a magic bullet. It will not cure long covid and will not help all long covid patients. However, HRT will very effectively and safely treat hormone deficiency that may be causing or exacerbating long covid symptoms in many women. £20 million has been invested in long covid research in the UK, but none has been allocated to studies evaluating the role of hormones or HRT in this patient group. It is not sufficient to cite a ‘lack of evidence’ as a reason for denying women access to treatment, given the very limited treatment options for long covid, and that the benefits of HRT outweigh the risks for most women.
Shared decision making is key, clinicians should be aware of the link with female hormones, and patients enabled to decide whether they wish to trial HRT or not. It is disheartening that two and a half years after the start of the covid-19 pandemic, the impact of covid-19 on women’s health is not being given the attention it deserves.
References
[1] Seeland U, Coluzzi F, Simmaco M, Mura C, Bourne PE, Heiland M, Preissner R, Preissner S. Evidence for treatment with estradiol for women with SARS-CoV-2 infection. BMC Med. 2020 Nov 25;18(1):369. doi: 10.1186/s12916-020-01851-z. PMID: 33234138; PMCID: PMC7685778.
[2] Sudre CH, Murray B, Varsavsky T, Graham MS, Penfold RS, Bowyer RC, Pujol JC, Klaser K, Antonelli M, Canas LS, Molteni E, Modat M, Jorge Cardoso M, May A, Ganesh S, Davies R, Nguyen LH, Drew DA, Astley CM, Joshi AD, Merino J, Tsereteli N, Fall T, Gomez MF, Duncan EL, Menni C, Williams FMK, Franks PW, Chan AT, Wolf J, Ourselin S, Spector T, Steves CJ. Attributes and predictors of long COVID. Nat Med. 2021 Apr;27(4):626-631. doi: 10.1038/s41591-021-01292-y. Epub 2021 Mar 10. Erratum in: Nat Med. 2021 Jun;27(6):1116. PMID: 33692530; PMCID:
[3] FAIR Health. Patients diagnosed with Post-COVID Conditions. A FAIR Health White Paper, May 18, 2022.
[4] Thompson EJ, Williams DM, Walker AJ, Mitchell RE, Niedzwiedz CL, Yang TC, Huggins CF, Kwong ASF, Silverwood RJ, Di Gessa G, Bowyer RCE, Northstone K, Hou B, Green MJ, Dodgeon B, Doores KJ, Duncan EL, Williams FMK; OpenSAFELY Collaborative, Steptoe A, Porteous DJ, McEachan RRC, Tomlinson L, Goldacre B, Patalay P, Ploubidis GB, Katikireddi SV, Tilling K, Rentsch CT, Timpson NJ, Chaturvedi N, Steves CJ. Long COVID burden and risk factors in 10 UK longitudinal studies and electronic health records. Nat Commun. 2022 Jun 28;13(1):3528. doi: 10.1038/s41467-022-30836-0. PMID: 35764621; PMCID: PMC9240035.
[5] Davis HE, Assaf GS, McCorkell L, Wei H, Low RJ, Re'em Y, Redfield S, Austin JP, Akrami A. Characterizing long COVID in an international cohort: 7 months of symptoms and their impact. EClinicalMedicine. 2021 Aug;38:101019. doi: 10.1016/j.eclinm.2021.101019. Epub 2021 Jul 15. PMID: 34308300; PMCID: PMC8280690.
[6] Newson L, Lewis R, O’Hara M. Long Covid and menopause - the important role of hormones in Long Covid must be considered. Maturitas 2021 Oct;152:74. https://doi.org/10.1016/j.maturitas.2021.08.026.
[7] Master H, Chaudhry A, Gall N, Newson L, Glynne S, Glynne P. Draw on expert opinion to optimise care for long covid. Guidelines in Practice, June 2022.
Competing interests: No competing interests
Dear Editor
Went through with interest Greenhalgh et. al’s paper “Long Covid—an update for primary care” and earnestly believe it to be an important addition to academic literature on Covid-19. But as a primary care physician, it has left a few unsolved mysteries for me, some of which are highlighted here.
No doubt the primary care practitioner will benefit by identifying the cause (not explained otherwise) of a cardiac, neurological or respiratory dysfunction to a possible long Covid, but does that change his mode or methods of intervention? Does identifying cause (Long Covid) in any case change the course of the disease or most importantly help initiate prevention independent of the cardiac, neurological or respiratory status and prevent further deterioration? Although the fact remains that Long Covid may turn out to be the single leading cause of increase in prevalence of Non Communicable Diseases (NCDs), our understanding of the evolution long Covid is limited only to how it may manifest and not how to prevent or control it.
On the one hand, while we may be worried about Long Covid being under-diagnosed, on the other hand, we may end up over-diagnosing it. However, the fact remains that both these situations don’t make a difference as in the end we will be targeting the outcome of Long Covid (unexplained fatigue, cardiac, neurological or respiratory dysfunction) and not Long Covid itself. And are not we already doing that?
Dr. Sunil Kumar Raina, MD
Professor & Head Community Medicine
Dr. RP Govt. Medical College, Tanda (HP), India
ojasrainasunil@yahoo.co.in
Note: the opinions expressed are solely those of the author and should not be imputed to any public or private entities.
1. Greenhalgh T, Sivan M, Delaney B, Evans R, Milne R. Long covid—an update for primary care BMJ 2022; 378 :e072117 doi:10.1136/bmj-2022-072117.
Competing interests: No competing interests
Dear Editor
Reviewing Greenhalgh et. al’s practice pointer (1) and the companion piece from Long Covid SOS (2) serve as a reminder from the COVID-19 public health emergency’s ongoing impact of the apt observation that “there is no health without mental health.”(3) Mental health conditions and substance use disorders, often co-occurring, have been among the most visible and widespread of COVID-19’s historic impacts. Throughout the pandemic, those with behavioral health conditions were among those facing heightened risks of adverse outcomes relative to the general population. (4,5).
COVID-19 has exacerbated barriers for those whose mental health conditions and substance use disorders preceded the pandemic and confronted individuals and communities with challenges that have likely contributed to increased incidence of these conditions. (6, 7,8). However, there is no shortage of best and promising practices to improve behavioral health in COVID’s wake, lessons to be learned at the local, state, tribal, federal and even international levels. (9).
The importance of supporting those with new onset or exacerbated behavioral health conditions is one essential element of efforts to support patients with long-term impacts of COVID-19. Greenhalgh et. al. specifically note “mental health and well-being” as one key component of primary care in assessing and treating long COVID patients. Screening for and identifying potential substance use disorders, co-occurring with mental health conditions or separate, also is important.
In the United States, the Department of Health & Human Services (HHS) renewed its public health emergency declaration for the opioid crisis, initially declared in October 2017, in January 2020, one week prior to the first US HHS declaration of emergency for COVID-19 (https://www.phe.gov/emergency/news/healthactions/phe/ Pages/default.aspx). For the past two years, these two declarations each have been renewed in close succession, a reflection of and reminder that the nation’s behavioral health challenges preceded and likely will outlast the more recent COVID pandemic.
President Joseph Biden in April 2022 issued a memorandum to US federal agencies requiring a “Government-wide response to the long-term effects of COVID-19” including behavioral health impacts. (10). In August 2022, the US federal government issued two reports on long COVID, one addressing Services and Supports for Longer-Term Impacts of COVID-19 and the other discussing a National Research Action Plan on Long COVID (Both reports are available at https://www.covid.gov/longcovid). These plans note the importance of behavioral health in efforts to support those with longer term complications of COVID-19.
Emphasizing behavioral health is one key part of addressing the current and long-term impacts of COVID-19, and preparing for the ‘next pandemic.’ More broadly, ensuring a well-funded, sustainable and adequately staffed behavioral health services at all levels of government and within the private and philanthropic sectors is among the most essential lessons we collectively can learn from COVID-19.
Mitchell Berger, MPH
Substance Abuse and Mental Health Services Administration
5600 Fishers Lane, Rockville, MD
Department of Health & Human Services*
Note: the opinions expressed are solely those of the author and should not be imputed to any public or private entities.
1. Greenhalgh T, Sivan M, Delaney B, Evans R, Milne R. Long covid—an update for primary care BMJ 2022; 378 :e072117 doi:10.1136/bmj-2022-072117.
2. The needs of patients with long covid must not be ignored BMJ 2022; 378 :o2287 doi:10.1136/bmj.o2287.
3. No Health without Mental Health: The Urgent Need to Integrate Mental Health in Universal Health Coverage, United for Global Mental Health, Dec. 2021, https://unitedgmh.org/resource-library.
4. Teixeira AL, Krause TM, Ghosh L, Shahani L, Machado-Vieira R, Lane SD, Boerwinkle E, Soares JC. Analysis of COVID-19 Infection and Mortality Among Patients With Psychiatric Disorders, 2020. JAMA Netw Open. 2021 Nov 1;4(11):e2134969. doi: 10.1001/jamanetworkopen.2021.34969.
5. Fond G, Nemani K, Etchecopar-Etchart D, Loundou A, Goff DC, Lee SW, Lancon C, Auquier P, Baumstarck K, Llorca PM, Yon DK, Boyer L. Association Between Mental Health Disorders and Mortality Among Patients With COVID-19 in 7 Countries: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2021 Nov 1;78(11):1208-1217. doi: 10.1001/jamapsychiatry.2021.2274.
6. 2021 Progress Report: The Impact of COVID-19 on People with Disabilities, National Council on Disability, Oct. 2021, https://ncd.gov/progressreport/2021/2021-progress-report
7. Panchal N, Kamal R, Cox C et. al., The Implications of COVID-19 for Mental Health and Substance Use, Kaiser Family Foundation, Oct. 2021. Accessed Jan. 23, 2022. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of....
8. SAMHSA releases 2020 National Survey on Drug Use and Health, Oct. 26, 2021. https://www.samhsa.gov/newsroom/press-announcements/202110260320.
9. Addressing the Long-Term Effects of COVID-19, Addressing the Long-Term Effects of COVID-19, 87 FR 20995, April 5, 2022, https://www.federalregister.gov/documents/2022/04/08/2022.
10. Campion J., Javed A, Lund C, et al. Public mental health: required actions to address implementation failure in the context of COVID-19, Lancet Psychiatry. 2022; 9: 169–82 DOI:https://doi.org/10.1016/S2215-0366(21)00199-1.
Competing interests: No competing interests
‘Functional’ is an unhelpful term in long covid
Dear Editor
The terms ‘organic’ and ‘functional’ are misleading. They imply a clear (Cartesian) split between illnesses of the body and those of the mind [1]. Long covid symptoms have been shown to be associated with various structural abnormalities in different organs and derangement of physiological function [2,3]. Like any other medical condition, long covid also includes an element of mental processing of symptoms and emotional and psychological reaction to the illness and the limitations it confers. We did not ignore these aspects of long covid; we included them as key elements of a whole-person condition that requires whole-person management.
The patient’s symptoms may be many, varied and fluctuating; no single biomarker exists to confirm or exclude long covid. Rather than label this pattern as ‘functional’, we need to listen carefully to the patient’s story, do a physical examination and relevant investigations, exclude alternative diagnoses, make and record the diagnosis of long covid, and direct the patient to self-management resources, support groups, and professionals with appropriate expertise.
Multidisciplinary rehabilitation is an effective approach even in so-called ‘functional’ or ‘medical unexplained’ conditions [4,5]. Using terms such as ‘psychological’ or ‘functional’ is unlikely to be helpful in engaging patients in treatment plans.
Rather than polarizing around outdated taxonomies, we should all acknowledge that prompt assessment and holistic management of the whole patient is what patients deserve and what the health service should be offering for long covid.
References
1 Thibaut F. The mind-body Cartesian dualism and psychiatry, Dialogues in Clinical Neuroscience 2018; 20:1, 3-3, DOI: 10.31887/DCNS.2018.20.1/fthibaut
2 Matheson AM, McIntosh MJ, Kooner HK, Lee J, Desaigoudar V, Bier E, Driehuys B, Svenningsen S, Santyr GE, Kirby M, Albert MS. Persistent 129Xe MRI Pulmonary and CT Vascular Abnormalities in Symptomatic Individuals with Post-Acute COVID-19 Syndrome. Radiology. 2022 Jun 28:220492.
3 Benedetti F, Palladini M, Paolini M, Melloni E, Vai B, De Lorenzo R, Furlan R, Rovere-Querini P, Falini A, Mazza MG. Brain correlates of depression, post-traumatic distress, and inflammatory biomarkers in COVID-19 survivors: A multimodal magnetic resonance imaging study. Brain, behavior, & immunity-health. 2021 Dec 1;18:100387.
4 Heruti R, Levy A, Adunski A. Conversion motor paralysis disorder: overview and rehabilitation model. Spinal Cord 2002; 40: 327–334https://doi.org/10.1038/sj.sc.3101308
5 Aybek S, Perez DL. Diagnosis and management of functional neurological disorder.BMJ. 2022; 376: o64.
Competing interests: TG is a member of Independent SAGE. MS is WHO Europe adviser on covid rehabilitation policy and led the development of the C19-YRS (Yorkshire Rehabilitation Scale) outcome measure for long covid. RE and TG are members of the NHS England Task Force for long covid.