You probably haven’t heard of these treatment options for Long COVID

About 7% of adults in the US—roughly 17 million people—reported currently having Long COVID in March 2024. Long COVID goes by many names, including:

• Long-haul COVID

• Post-COVID conditions (PCC)

• Post-acute COVID-19

• Post-acute sequelae of SARS-CoV-2 infection (PASC)

• Chronic COVID

• Long-term effects of COVID

People with Long COVID may have a number of symptoms that last for weeks, months, or years after infection with the virus that causes COVID-19. Different people experience different symptoms with varying severities. These may include:

• Fatigue, weakness

• Brain fog (problems thinking or concentrating)

• Symptoms that get worse after physical or mental effort (known as post-exertional malaise, PEM)

• Lung (respiratory) symptoms, including difficulty breathing or shortness of breath, and cough

• Neurological symptoms, including headache, sleep problems, dizziness when you stand, pins-and-needles sensation, loss of smell or taste

• Depression or anxiety

• Joint or muscle pain

• Heart symptoms or conditions, including chest pain and fast or pounding heartbeat, or a feeling of skipped heartbeats (palpitations)

• Digestive symptoms, including diarrhea and stomach pain

• Blood clots and blood vessel (vascular) issues

• Other symptoms, such as a rash, vision problems, bladder problems, fever/sweats, hair loss, ear ringing, and changes in the menstrual cycle

There is no single test to diagnose Long COVID. It’s a clinical diagnosis, meaning that a doctor diagnoses it based on a patient’s history of having had COVID-19 at some point, with the above symptoms following the infection. It’s a diagnosis of exclusion, meaning it’s necessary to first rule out other possible causes of these symptoms. Of note, a positive COVID test is not required to establish a diagnosis of Long COVID since many people had COVID but did not test.

There is no standard treatment for Long COVID at this time. There are, however, many medications that have been trialed in patients with Long COVID. Several studies have been conducted, and there are also many case reports where doctors share their clinical experiences of the medications they’ve tried with their patients and the results. These aren’t formal studies, but the information is invaluable. This is often how different uses for many current medications are discovered and then go on to be formally tested in studies.

The treatment options below are just that—options. There’s no way to know beforehand which will help you specifically. However, given the minimal side effects of many of these medications and the potential to feel better, most people are comfortable trying them. As always, speak with your doctor to determine the risk/benefit ratio of trialing any of these medications in your specific case. (I have linked research and resources below.)

Medications for fatigue/brain fog/low mood:

• Cetirizine or other antihistamines, such as Loratadine or Fexofenadine (H1 receptor blocker)

• Famotidine (H2 receptor blocker)

• Nicotine patch

• Low-dose naltrexone (from a compounding pharmacy, up to 4.5 mg nightly)

• Low-dose aripiprazole (up to 2 mg daily)

• Guanfacine + NAC (N-acetylcysteine)

• Low-dose lithium (up to 75–150 mg lithium carbonate daily)

• Fluoxetine (low dose, up to 10 mg daily)

• Atomoxetine, Viloxazine, Stimulants

Other medications:

• Amitriptyline - for headaches or insomnia

• Pregabalin and Gabapentin - for nerve pain

Vitamins:

• L-Arginine + Vitamin C

• Alpha-lipoic acid + Coenzyme Q10

• Vitamin D

• D-ribose

• Pycnogenol

• Probiotics

• NAD+

• Omega-3 fatty acids (Vascepa = prescription version)

• Melatonin (for insomnia)

Nutrition/lifestyle:

• Aggressive hydration (at least 80 oz of water daily)

• 100+ grams of protein intake daily

• Low sugar intake (not low carb—low added sugar, high fiber)

• Trial of gluten avoidance

For POTS (postural orthostatic tachycardia syndrome = dizziness when you stand, increase in HR upon standing - read more here)

• Compression stockings

• Increased salt intake

• Beta-blocker (Toprol or Nadolol) or calcium channel blocker (Diltiazem)

• Medications to consider:

  • Fludrocortisone

  • Midodrine

  • Propranolol

  • Clonidine

  • Pyridostigmine

  • Ivabradine

Other interventions:

• Hyperbaric oxygen

• Stellate ganglion nerve blockade

• Vagus nerve stimulation

• Repetitive transcranial magnetic stimulation (rTMS)

Although not widely spoken about, there are several options for treating Long COVID, from medication to supplements to non-invasive interventions. More are being discovered. At Brain-Body Psychiatry, we are proud to provide multiple treatment options to people struggling with Long COVID. You deserve to feel better.

With care,

Dr. Luisa Cacciaguida

Sources:

(of note, Long COVID is similar to myalgic encephalomyelitis (ME) and chronic fatigue syndrome (CFS) (read about it here), so a few of the studies below are on ME/CFS)

• CDC Long COVID Household Pulse Survey

• Therapeutic trials for long COVID-19: A call to action from the interventions taskforce of the RECOVER initiative

• Fluoxetine plus lithium for treatment of mental health impairment in Long Covid

• Efficacy and Safety of Lithium Treatment in SARS-CoV-2 Infected Patients

• Low-dose naltrexone and NAD+ for the treatment of patients with persistent fatigue symptoms after COVID-19

• Low-dose naltrexone use for the management of post-acute sequelae of COVID-19

• Clinical experience with the α2A-adrenoceptor agonist, guanfacine, and N-acetylcysteine for the treatment of cognitive deficits in “Long-COVID19”

• Yale Medicine Potential New Treatment for “Brain Fog” in Long COVID Patients

• Amitriptyline for post-COVID headache: effectiveness, tolerability, and response predictors

• Oral famotidine versus placebo in non-hospitalised patients with COVID-19: a randomised, double-blind, data-intense, phase 2 clinical trial

• Effect of famotidine on cognitive and behavioral dysfunctions induced in post-COVID-19 infection: A randomized, double-blind, and placebo-controlled study

• Antihistamines for Postacute Sequelae of SARS-CoV-2 Infection

• Antihistamines improve cardiovascular manifestations and other symptoms of long-COVID attributed to mast cell activation

• Off label use of Aripiprazole shows promise as a treatment for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): a retrospective study of 101 patients treated with a low dose of Aripiprazole

• Successful Treatment of Post-COVID-19 ADHD-like Syndrome: A Case Report

• Emerging Psychiatric Themes in Post-COVID-19 Patients on a Psychiatry Consultation-liaison Service

• Proposed Long-COVID workup and treatment approach from the clinics of Drs. Alex Truong, Tiffany Walker, and Thanushi Wynn

• A pilot randomized controlled trial of supervised, at-home, self-administered transcutaneous auricular vagus nerve stimulation (taVNS) to manage long COVID symptoms

• Vagus Nerve Stimulation for the Treatment of Post–COVID-19 Condition

• Effect of Repetitive Transcranial Magnetic Stimulation on Long Coronavirus Disease 2019 with Fatigue and Cognitive Dysfunction

• Stellate Ganglion Block Relieves Long COVID-19 Symptoms in 86% of Patients: A Retrospective Cohort Study

• Stellate Ganglion Block for Long COVID Symptom Management: A Case Report

• The Use of D-Ribose in Chronic Fatigue Syndrome and Fibromyalgia: A Pilot Study

• Gut Microbiota Dynamics in Relation to Long-COVID-19 Syndrome: Role of Probiotics to Combat Psychiatric Complications

• Coenzyme Q10 + alpha lipoic acid for chronic COVID syndrome

• Low Vitamin D Levels Are Associated With Long COVID Syndrome in COVID-19 Survivors

• Effects of l-Arginine Plus Vitamin C Supplementation on Physical Performance, Endothelial Function, and Persistent Fatigue in Adults with Long COVID: A Single-Blind Randomized Controlled Trial

• Combining L-Arginine with vitamin C improves long-COVID symptoms: The LINCOLN Survey

• The Use of D-Ribose in Chronic Fatigue Syndrome and Fibromyalgia: A Pilot Study

• Effects of Pycnogenol® in people with post-COVID-19 condition (PYCNOVID): study protocol for a single-center, placebo controlled, quadruple-blind, randomized trial

• Preventive effects of Pycnogenol® on cardiovascular risk factors (including endothelial function) and microcirculation in subjects recovering from coronavirus disease 2019 (COVID-19).

• NAD+ in COVID-19 and viral infections

• Treatment of Long COVID or Post COVID syndrome: A Pharmacological approach

• Proposing Vascepa (Icosapent Ethyl) as Supplemental Treatment Targeting the Underlying Causes of Persistent, Post-Viral Symptoms Associated with COVID-19: A Case Series

• Omega-3 polyunsaturated fatty acids and the psychiatric post-acute sequelae of COVID-19: A one-year retrospective cohort analysis of 33,908 patients

• Is the post-COVID-19 syndrome a severe impairment of acetylcholine-orchestrated neuromodulation that responds to nicotine administration?

Disclaimer:

This blog post is intended to be informative and does not replace individual medical advice. Always consult with your healthcare provider or a professional for any personal medical decisions or concerns you may have. Everyone's health situation is unique and should be evaluated by a healthcare professional.

This blog post is designed as a general guide. This is not a substitute for personalized medical advice, nor is a patient-physician relationship established in this blog post.