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When Allison Saulino, 46, came down with COVID-19 in August 2021, she assumed she'd bounce back quickly, as she was fully vaccinated and otherwise healthy. But once she recovered, she still had a chronic cough that left her exhausted and prevented her from doing her daily activities.
"I would cough nonstop to the point that I couldn't catch my breath," says Saulino, who lives in Hilliard, Ohio.
She assumed the cough would improve, but it didn't, until her symptoms worsened and she ended up in the emergency room in early December, convinced she was having a heart attack.
"They told me that it was due to inflamed muscles, that there was nothing they could do, and that this was my new 'normal,'" she says. "I burst into tears. No one wants to live this way."
Saulino contacted the Post-COVID Recovery Program at the Ohio State University Wexner Medical Center. At her first visit in December, she met with a pulmonologist who told her she had gotten asthma after her bout with COVID. After 5 weeks on the twice-daily maintenance inhaler beclomethasone (Qvar), her symptoms were gone. In fact, the only time she gets an asthma flare now is if she has a cold.
Saulino says that she feels back to herself again, including having the energy to get her 18-year-old quadruplets off to college this fall. "But if I hadn't been persistent, and sought out treatment, I'd probably still be incredibly debilitated," she says.
Not all people who live with long COVID find a solution that works so well, or so quickly. But as long COVID clinics have sprouted up across the country, there are more and more options for patients who deal with lingering, but life-altering symptoms.
"It can be challenging for doctors to treat, since many people undergo extensive testing, which doesn't turn up anything abnormal," says David Putrino, PhD, director of rehabilitation innovation at the Mount Sinai Health System in New York City. "But their symptoms are very real."
The FDA has approved or authorized four treatments for COVID-19 itself:
Monoclonal antibodies. These help your immune system recognize and fight the COVID-19 virus. They are usually given as an IV or at an infusion center.
Paxlovid (nirmatrelvir and ritonavir). This is a combination of two virus-fighting drugs that are taken together as pills twice a day for 5 days.
Molnupiravir. This is a pill that's taken twice a day for 5 days.
Remdesivir. This antiviral, given as an IV, can slow the spread of the virus in the body.
In addition, doctors can offer COVID-19 patients blood thinners to prevent blood clots and may treat hospitalized patients with immune system modulators to slow the overreaction of the immune system, as well as steroids.
But treatment for long COVID itself remains more elusive.
"We really triage based upon symptoms to subspecialists such as cardiologists, rehabilitative medicine specialists, neurologists, or psychologists, and then judiciously apply medications to treat them," says Daniel Sterman, MD, director of the Division of Pulmonary, Critical Care and Sleep Medicine at NYU Langone Health in New York City. "We don't have antiviral medications like we do for the actual COVID-19 virus itself, to treat an underlying root cause."
The Importance of a Diversified Approach
"Many people have symptoms that affect multiple organs, such as their brain, heart, and lungs," says Andrew Schamess, MD, a professor of internal medicine at the Ohio State Wexner Medical Center who runs the Post-COVID Recovery Program.
Since there isn't yet a good sense of what drives long COVID, treatment usually focuses on symptom relief, he says.
Long COVID seems to make other conditions worse, he says.
"Someone with mild asthma may now be constantly coughing or wheezing, or perhaps a patient had mild undiagnosed fibromyalgia that worsened considerably after their encounter with the virus. If we can identify some of these diseases, and treat them, then often we can go a long way."
People seeking treatment for long COVID may see and be treated by at least one of these specialists, says Schamess:
Sleep medicine specialist
Under the best circumstances, these specialists would work together to try to get a big picture of symptoms and possible causes, Schamess says.
What Treatment Entails
The following are some of the most common treatments for long COVID:
Pulmonary rehabilitation. This helps patients who got pulmonary fibrosis, or scarring and damage to their lung tissue, after COVID-19, as well as anyone who complains of shortness of breath, says Sterman. "You'll work with a physical therapist or rehabilitative medicine specialist to improve your exercise capacity and be taught a variety of breathing and biofeedback techniques to help you experience less shortness of breath," he says.
Autonomic conditioning therapy. This is sometimes used to treat some of the changes in the nervous system that can be seen with long COVID, such as heart palpitations, dizziness, and shortness of breath. "The goal of this therapy is to slowly and very gently challenge the autonomic nervous system," says Putrino.
The autonomic nervous system controls things your body does without you thinking about them, such as heart rate and breathing. "In a person with autonomic dysfunction, a simple exercise like a heel slide (in which the patient lies on the floor and slides a heel to the buttocks) can cause blood to flow back into the thigh and chest cavity, which causes the heart rate to go up significantly. "We can work with them to teach them breathing exercises that will help prevent some of these changes in heart rate," says Putrino. One small study done by Putrino found that patients with long COVID who did autonomic conditioning therapy with a physical therapist for 30 minutes twice a week reported improvements in fatigue, compared to those who didn't.
Cognitive rehabilitation. Almost a third of all patients with long COVID have "brain fog," where inflammation damages brain cells and causes symptoms such as problems with memory, attention, and concentration. In these cases, patients may benefit from cognitive rehabilitation therapy, says Schamess. This therapy, typically used to treat patients recovering from a concussion, traumatic brain injury, or stroke, includes memory training, speech therapy, and cognitive exercises, and usually lasts about 6 to 8 weeks, says Schamess.
Smell retraining therapy. This may help people who have lost their sense of smell and taste. "We have patients take things that have a distinctive odor, like essential oils, coffee, or oranges, and have them hold them under their nose for a minute or two," says Schamess. "The idea is to jump-start their olfactory neurons." Some research also suggests that it may be more effective if it's paired with a sinus rinse that includes steroids.
Lack of Specific Drugs for Long COVID
Unfortunately, there aren't any drugs available to specifically treat long COVID.
"The trials to look at these types of therapies in the context of long COVID just haven't been done yet," says Jennifer Frontera, MD, a neurologist at NYU Langone Health who works frequently with long COVID patients. "Since we don't have strong data on how to treat patients, right now we really focus on best ways to manage symptoms."
Here's a look at a few drugs that are commonly prescribed:
Amitriptyline. This antidepressant may help with some of the sleep disturbances and headaches that are linked to COVID-19, says Frontera.
Gabapentin. This is an anti-seizure medication that is often used by doctors to treat nerve pain. It can be helpful to treat pain and numbness in the hands and legs, as well as fibromyalgia-type symptoms often seen in long COVID patients, Frontera says.
Antidepressants. Drugs known as selective serotonin reuptake inhibitors (SSRIs), including sertraline or fluoxetine, are often the first-line treatment for symptoms of depression and anxiety. "These are traditionally considered mood disorders, but we believe that long COVID actually causes imbalances in certain neurotransmitters, or brain chemicals, that need to be fixed," says Frontera.
Drugs to treat low blood pressure. Some patients with long COVID get postural orthostatic tachycardia syndrome (POTS), which affects heart rate and blood pressure. When people stand, heart rate and blood pressure can drop suddenly, causing dizziness. Several drugs can help, says Schamess, including fludrocortisone, which boosts blood volume, and midodrine (Orvaten), which raises blood pressure. Some doctors also prescribe salt tablets. For older patients who have high blood pressure, the best option is beta-blockers, Schamess says.
In the Future
Researchers are exploring treatments that may get to the source of long COVID. For example:
A study published this past June in the journal PLOS Pathogens found that patients with long COVID had levels of virus-specific T cells more than 100 times higher than those who recovered from the infection. The theory is that the virus hides in the body and causes long-term symptoms. This may mean researchers need to focus on vaccines and antiviral medications such as Paxlovid that help clear the virus from a patient's system.
A study of mice published in early July found that molnupiravir — one of the FDA-authorized antivirals for the treatment of COVID-19 — reduced the risk of long COVID symptoms in mice that had had gotten lung inflammation after infection.
A 2021 study published in the Journal of Thrombosis and Haemostasis found that patients with long COVID had higher blood levels of clotting markers than healthy controls. Researchers said this may help explain symptoms such as reduced physical fitness and fatigue, and may mean that some patients with long COVID may respond to treatment with blood thinners.
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Cite this: Hallie Levine. No Long COVID Drugs Yet, But Other Treatments Available - Medscape - Jul 27, 2022.