Many aspects of long covid remain a mystery, but rheumatologists are getting closer to working out what drugs make effective treatments.
As the only rheumatologist working in San Diego’s multidisciplinary long covid clinic, Dr Susan Lee has five main medicines in her pharmaceutical arsenal, each corresponding to a different phenotype of the condition.
Her first job is to rule out any new onset connective tissue disease or myopathy and judge whether the patient’s condition is more along the lines of fibromyalgia or chronic fatigue.
Next up is taking a look at their sleep pattern.
“If sleep is their main complaint, then I usually go with tricyclic [antidepressants] to help with sleep and … fatigue, and the data [to support that] is coming from chronic fatigue syndrome literature,” Dr Lee told delegates at the American College of Rheumatology Convergence annual meeting this week.
When a patient presents with pain as their predominant complaint, she normally prescribes SNRIs alongside physical therapy and acupuncture.
For patients who are fatigued but sleeping well or who are intolerant of tricyclics or who decline to try tricyclics, Dr Lee often trials them on a low dose of opioid antagonist naltrexone.
Low dose aripiprazole (Abilify, Otsuka Pharmaceutical Co.) has proved helpful for alleviating fatigue, she said, while N-acetylcysteine (NAC) and guanfacine appear to help with brain fog, but not fatigue.
Dr Lee presented on the long covid panel at ACR Convergence in San Diego on Sunday, alongside rheumatologists Dr Cassandra Calabrese and Dr Zachary Wallace, and rehabilitation medicine specialist Dr Monica Verduzco-Gutierrez.
Dr Verduzco-Gutierrez, who runs the long covid clinic at University of Texas San Antonio and is involved with the RECOVER study, said the first thing she tries for new patients with fatigue is pacing, a strategy to help prevent post exertional malaise.
“[Physical therapists] have to understand long covid and the pathophysiology,” Dr Verduzco-Gutierrez said.
“A lot of [patients] have these underlying myalgic encephalitis/chronic fatigue syndrome type symptoms and … if you give them traditional graded exercise programs, they will crash and they will get worse.
“Then they will maybe become the bed-bound ME/CFS type patient.”
Part of physical rehabilitation for these patients, she told delegates, is about limiting what they do in one day.
Dr Verduzco-Gutierrez also said that breath work and autonomic reconditioning had led to huge improvement in some patients, particularly the subset with dysautonomia.
From the audience, there were multiple questions on vaccination – specifically, whether or not they should be encouraging their patients to stay up to date on variant-specific boosters.
The general consensus among panellists was that if patients had done well on previous vaccines, it would probably be beneficial for them to stay up to date.
“The conversation I have with my patients is that if they are not high risk … I don’t blame them if they don’t want to get another vaccine,” Dr Calabrese told delegates.
“The way I look at it is, moving forward, the goal of covid vaccines is to prevent severe outcomes [such as] being in the hospital or dying from covid.
“They’re not going to stop you from getting covid, so if you are not at risk for those outcomes you probably don’t stand to benefit a lot from getting another vaccine right now.”
Still, the only group of patients that Dr Calabrese encourages against getting booster shots are those who have had true adverse events, such as tinnitus, from a previous mRNA vaccine.
ACR Convergence 2023 took place between 10 and 15 November at the San Diego Convention Center.