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First off, a disclaimer; anyone reading this will surely know that our understanding of long COVID is in its nascency. Many of these answers are a ‘best guess’ based on today’s data and will doubtless change over time as more information becomes available.
What is long covid and how is it diagnosed?:
While there is widespread agreement that Post-Acute Sequelae of SARS-CoV-2 infection (PASC), or ‘long covid’, consists of ongoing symptoms beyond what would typically be expected after recovering from Covid, experts vary in the duration that qualifies as long covid, with a range between ~2-3 months of from the onset of COVID-19. There are no specific tests to determine whether a person has long covid, thus the diagnosis is clinical.
What are the three most common symptoms of long covid?
Less common:
Chest pain, anxiety, depression, difficulty speaking, muscle aches, loss of smell and/or taste
Duration:
Variable, typically ~ several weeks - 6 months (up to 9 months and longer reported)
How likely is it that a person will develop long covid after an initial infection?
Debatable; percentages vary from single digits up to ~ 50%.
Does anything increase the risk of long covid?
Studies suggest that older people, those with a more serious initial Covid-19 infection and/or those with certain underlying comorbid conditions (such as chronic lung disease, diabetes, and heart disease) may be at greater risk of developing long covid. There is also some evidence that women may be more prone to long covid, and that vaccination may confer a degree of protection against long covid, but this data is still emerging.
How is long covid treated?
Because long covid can involve many different body systems, a multidisciplinary approach and a range of treatments directed toward the specific body systems affected are key. Although it can be tempting to rush back to normal activities, post-exertional malaise–meaning profound fatigue with overexertion–is common. Rehabilitation can help direct a gradual return to activity and promote recovery.
Non-oral COVID-19 Treatment Options in the Outpatient Setting
The proliferation of treatment options for SARS-CoV-2 can be seen as one of the success stories of the global COVID-19 pandemic.
Individuals who have been diagnosed with COVID-19 and are at high risk of hospitalization may be eligible for treatment with non-oral medications which have received FDA approval or emergency use authorization (EUA). These medications are administered intravenously (IV), typically in an infusion center. They can be divided into two categories: 1) monoclonal antibodies and 2) antiviral drugs.
Antibody Therapy:
Monoclonal antibodies are synthetic versions of antibodies made by the immune system against SARS-CoV-2. The body’s immune system typically takes a couple of weeks to build up antibodies against SARS-CoV-2 after an exposure (either via infection with the virus or via vaccination), therefore the administration of synthetic antibodies can effectively fast-track this targeted immune defense. Antibody treatments work by binding to certain key parts of the virus, blocking the virus from binding to and entering cells.
Antibody treatments with EUA for outpatient use include sotrovimab and bebtelovimab.
Antiviral Therapy:
Remdesivir is an antiviral drug that was previously authorized for use in hospital patients, but just recently (end of January 2022) received FDA authorization for outpatient use. Remdesivir works by incorporating into the viral RNA (ribonucleic acid), inhibiting the ability of SARS-CoV-2 to replicate.
What Are the Treatment Criteria?:
All three of the above medications are approved for use in adult or pediatric (age 12 yo and older, weighing ≥ 40 kg) patients who have mild-to-moderate symptomatic COVID-19 and who are at high risk of progression to hospitalization. In order to be efficacious, they should be started as soon as possible, no later than 7 days after symptoms began.
How Well Do The Treatments Work?
Studies have demonstrated > 80% efficacy of both remdesivir and sotrovimab for preventing hospitalization or death due to COVID-19 (if started with 7 days of symptom onset). Data are still emerging for bebtelovimab; preliminary studies have also shown a reduction in hospitalization or death in high-risk patients.
What Are the Common Side Effects?:
Monoclonal antibody treatments for COVID-19 are generally well tolerated. The most commonly reported side effects are injection site reactions and infusion-related reactions (1% of patients who received sotrovimab experienced infusion-related reactions).
The most common side effects following administration of Remdesivir were nausea, headaches, and rash. Elevated liver enzymes (a laboratory finding) are common in patients who receive Remdesivir, and caution is advised in those individuals with liver or kidney disease.
Two years into the global pandemic, antiviral pills have emerged as a new therapeutic option. In late December of 2021, the FDA gave emergency use authorization (EUA) to two oral antiviral treatments for COVID-19: Paxlovid (Pfizer Inc.) and molnupiravir (Merk & Co). These hotly anticipated medications are intended for use in newly infected individuals who are at high risk of developing severe disease.
How do they work?
Paxlovid is a combination of two different medications, nirmatrelvir and ritonavir. Paxlovid blocks a key type of enzyme, called a protease, which cuts up SARS-CoV-2 (the virus which causes COVID-19) proteins into their active forms. When the protease is blocked, the virus can’t replicate (~90% of viral replication is inhibited), and the infection slows down, allowing the immune system to ramp up and fight the remaining virus.
Molnupiravir is incorporated into the RNA (the genetic blueprint) of SARS-CoV-2, resulting in defective genetic material and effectively stopping the virus from multiplying.
When and in whom can they be used?
Both pills are indicated for use in patients who are covid positive, symptomatic with mild to moderate disease, and at high risk of progression to severe disease. The treatments work best when started as soon as possible after a COVID-19 diagnosis and they must be started within five days of symptom onset. They are administered twice daily for five days.
Paxlovid: authorized for use in all adults and in children who are 12 years or older and weigh at least 88 pounds. There is a high potential for drug interactions (eg statins, blood thinners) with Paxlovid; make sure to inform your health care provider which other medications and over-the-counter supplements you are taking. Paxlovid may not be appropriate for individuals with liver disease, kidney disease, or those infected with the HIV virus
Molnupiravir: authorized for use in adults 18 or older. Cannot be used in pregnant or breastfeeding women. Molnupiravir is only approved for use in those “...for whom alternative COVID-19 treatment options authorized by the FDA are not accessible or clinically appropriate”.
How WELL do the treatments work?
In the studies cited by the FDA, Paxlovid reduced the rate of COVID-19 related hospital admission or death by ~88% and molnupiravir by ~ 33%.
What are the most common side effects?
Paxlovid: altered taste or loss of taste, diarrhea, high blood pressure, muscle aches
Molnupiravir: diarrhea, nausea, dizziness
* If you have recently been diagnosed with COVID-19, developed symptoms within the past five days, and think you may be eligible for one of the oral antiviral medications (eg you are at high risk of severe disease), please reach out to your health care provider.
The new year found Americans mired in the peak of yet another SARS-CoV-2 wave, with the preceding holiday season scarred by overstretched health care systems and testing capacity. In response, the Biden administration has increased the accessibility of at-home COVID-19 tests on multiple fronts.
In January 2022, all US households became eligible to request four free rapid COVID-19 tests either via the website, COVIDTests.gov, or by calling 800-232-0233.
At the same time, the government also mandated that private health insurers cover up to eight at-home antigen tests per month, per covered individual, with reimbursement capped at $12 per testing kit (two tests per kit). Out of pocket costs vary between ~$10-25 per kit. Typically, the insurance provider will cover the upfront cost for in-network pharmacies and retroactively reimburse members who buy test kits from out-of-network pharmacies.
Although Medicare was not initially included in the coverage mandate, at the beginning of February the Biden administration announced that Medicare beneficiaries, including Medicare Advantage, would also become eligible for eight free at-home COVID-19 antigen tests per month, beginning in the early spring.
The expanded coverage will include over 60 million Americans, many of whom fall into the higher risk health category.
Medicaid recipients already have full coverage of at-home COVID-19 tests (8 per month).
At the most basic level, there are two categories of COVID-19 tests; a diagnostic test and an antibody test. A diagnostic test can diagnose a current infection, whereas an antibody test can tell you whether your immune system has been exposed to COVID-19 (either via infection or vaccine) in the past. An antibody test cannot be used to diagnose a current infection.
Diagnostic tests include PCR (polymerase chain reaction) and antigen tests.
PCR is considered the “gold standard” for diagnosing infection with COVID-19. It is a molecular test that looks for COVID-19’s genetic material (RNA). PCR is very sensitive, meaning that almost everyone who actually has a COVID-19 infection will have a positive test. PCR tests are analyzed in a lab and are most often performed in a health care setting, such as a clinic, doctors’ office, pharmacy, or designated testing center. If performed at home, the sample kit will need to be mailed to a lab for analysis. The samples are most commonly collected via a nasopharyngeal swab (the swab is inserted into the nostril and up toward the back of the nose) or a salivary sample. Result turnaround can vary from ~ 1-7 days. Due to the labor of the processing, they are fairly expensive, around $150 (without insurance coverage). During COVID-19 peaks, PCR results have often been quite delayed when testing capacity has not been able to meet high demand.
Antigen tests have the advantage of speed, with results available in ~ 15 minutes. Instead of genetic material, antigen tests search for protein pieces from the COVID-19 virus. They can be purchased over the counter, are performed at home via a nasal swab, and are less expensive than PCR tests, with prices running around $20-24 per kit (two tests per kit). Antigen tests are similar in design and appearance to a home pregnancy test, with a colored line designating ‘positive’ or ‘negative’ showing in the box at the top once the sample is finished processing. Antigen tests are less sensitive than PCR tests and may be negative early on in an infection.
If you are experiencing symptoms of COVID-19 and have a negative antigen test, it is recommended to obtain a PCR test and continue to isolate until the result of the PCR test is known (if results are delayed, then continue to isolate for 5 days at minimum, with symptoms resolving and 24 hours free of fever prior to ending isolation; continue wearing a well-fitting mask for an additional five more days after the isolation period has ended).
Because PCR tests are so sensitive, they can remain positive for up to twelve weeks after a person has recovered from COVID-19 and is no longer contagious. If you have been diagnosed with COVID-19 and subsequently recovered, an antigen test is the best test to determine if you are still shedding enough virus to transmit COVID-19 to other people.
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