NICE summary
The recommendations in this Best Practice topic are based on authoritative international guidelines, supplemented by recent practice-changing evidence and expert opinion. For your added benefit, we summarise below the key recommendations from relevant NICE guidelines.
Key NICE recommendations on diagnosis
Use the following clinical case definition to identify and diagnose 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.
Ongoing symptomatic COVID-19 includes signs and symptoms of COVID‑19 from 4 weeks up to 12 weeks.
The term ‘long COVID’ is commonly used to describe signs and symptoms that continue or develop after acute COVID‑19. It includes both ongoing symptomatic COVID‑19 (from 4 to 12 weeks) and post‑COVID‑19 syndrome (12 weeks or more).
Take a comprehensive clinical history, including:
History of acute COVID-19 (suspected or confirmed)
Nature and severity of previous and current symptoms
Timing and duration of symptoms since the start of acute COVID-19
History of other health conditions
Exacerbation of pre-existing conditions.
Discuss the person’s experience of their symptoms and how their life and activities have been affected, including work, education, mobility and independence.
Assess physical, cognitive, psychological and psychiatric symptoms, as well as functional abilities.
If appropriate, offer an exercise tolerance test suited to the person’s ability (e.g., the 1‑minute sit‑to‑stand test). During the exercise test, record level of breathlessness, heart rate and oxygen saturation. Follow an appropriate protocol to carry out the test safely.
For people with postural symptoms (e.g., palpitations or dizziness on standing), carry out lying and standing blood pressure and heart rate recordings (3‑minute active stand test for orthostatic hypotension, or 10 minutes if you suspect postural tachycardia syndrome, or other forms of orthostatic intolerance).
Offer tests and investigations tailored to the person’s signs and symptoms to rule out acute or life‑threatening complications and find out if symptoms are likely to be caused by ongoing symptomatic COVID‑19, post‑COVID‑19 syndrome or a new, unrelated diagnosis.
Offer a chest X-ray by 12 weeks after acute COVID-19 only if the person has continuing respiratory symptoms and it is clinically indicated. Chest X-ray appearances alone should not determine the need for referral for further care.
Decisions about blood tests should be guided by the person's symptoms. If clinically indicated, offer blood tests, which may include a full blood count, kidney and liver function tests, C‑reactive protein, ferritin, B‑type natriuretic peptide (BNP), HbA1c and thyroid function tests.
If the person reports new cognitive symptoms, use a validated screening tool to measure any impairment and impact.
Links to NICE guidance
COVID-19 rapid guideline: managing the long-term effects of COVID-19 (NG188) January 2024. http://www.nice.org.uk/guidance/ng188
Key NICE recommendations on management
Refer people with suspected post-COVID-19 syndrome urgently to the 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).
Refer people with suspected post‑COVID‑19 syndrome urgently for psychiatric assessment if they have severe psychiatric symptoms or are displaying high risk of self‑harm or suicide.
Follow relevant national or local guidelines on referral for people who have anxiety and mood disorders or other psychiatric symptoms. Consider referral:
For psychological therapies if they have common mental health symptoms, such as symptoms of mild anxiety and mild depression or
To a liaison psychiatry service if they have more complex needs (especially if they have a complex physical and mental health presentation).
After ruling out acute or life-threatening complications and alternative diagnoses, 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.
In the absence of indications for urgent referral, offer advice on self-management, with the option of supported self‑management and one or more of the following, depending on clinical need and local pathways:
Support from integrated and coordinated primary care, community, rehabilitation and mental health services
Referral to an integrated multidisciplinary assessment service
Referral to specialist care for specific complications.
Provide advice and information on:
Ways to self-manage symptoms, such as setting realistic goals
Who to contact if worried about symptoms or needing support with self‑management
Sources of advice and support, including support groups, social prescribing, online forums and apps
How to get support from other services, including social care, housing and employment, and advice about financial support
Information about new or continuing symptoms of COVID-19 to share with family, carers and friends.
Provide access to multidisciplinary services, if available, for assessing physical and mental health symptoms and carrying out further tests and investigations.
Use a multidisciplinary approach to guide rehabilitation, including physical, psychological and psychiatric aspects of management.
Ensure that any symptoms that could affect the person being able to start rehabilitation safely have been investigated first.
Work with the person (and their family or carers, if appropriate) to develop a personalised rehabilitation and management plan that is recorded in a rehabilitation prescription.
© NICE (2024) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights . All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Links to NICE guidance
COVID-19 rapid guideline: managing the long-term effects of COVID-19 (NG188) January 2024. https://www.nice.org.uk/guidance/ng188
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