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Long COVID Continues to Haunt Patients and Physicians Alike. Therapeutic Alternatives Are Needed

Op-Med is a collection of original articles contributed by Doximity members.

The American Academy of Asthma Allergy and Immunology 2023 annual meeting took place in San Antonio, Texas, between Feb 24-27, 2023. It was, as usual, an extraordinary meeting. Dr. Renata Engler and I

presented a seminar about the Integrative Medicine Treatment Modalities for Long COVID-19. 

The participants were physicians, nurses, and people from pharmaceutical companies. Some of the participants had experienced long COVID themselves. Some had COVID without any complications. They all had a common interest. They wanted to hear what other options may be available to improve their health status, as conventional medicine has little to offer. Long COVID can be present in up to 10 to 30% or more of confirmed SARS-CoV-2 infected patients after four or more weeks of the acute illness, even if they had a mild course of the disease or were asymptomatic during the acute infection. This disease is debilitating and does not discriminate between doctors, nurses, and patients; everyone can be affected. The patients may present with prolonged multisystem signs and symptoms, including chronic fatigue, 'brain fog,' shortness of breath, joint pain, and cough, among others. Autoimmunity has also been detected in long COVID. These symptoms cannot be explained by an alternative pathology. A particular symptom of acute and long COVID is anosmia and ageusia. The onset can be a continuum from the original disease, where patients do not recover, or these can appear after an apparent period of disease resolution. Long COVID resembles other post-viral diseases known as Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) that have been studied for over 50 years. Symptoms resembling postural orthostatic tachycardia syndrome (PoTS) are also present in long COVID. The pathophysiology of long COVID is complex, involving dysregulation in many components of the immune system and endothelial dysfunction among other affected body systems. Importantly, biomarkers involved in angiogenesis, such as Angiopoietin-1(ANG-1) and P-Selectin (P-SEL), have been shown to identify long COVID patients. With respect to interventions, we shared selected integrative medicine therapies that can be useful for some of the symptoms of long COVID:

Selected Integrative Medicine (IM) interventions for key symptoms of long COVID (or acute if noted):

  1. Acute COVID: Botanical Drugs and Supplements That May Be Safe and Useful in COVID-19 Brendler T et al. Botanical drugs and supplements affecting the immune response during COVID-19: implications for research and clinical practice. Phytother Res. 2021;35(6):3013-3031. doi:10.1002/ptr.7008 (Summary published in the American Botanical Council – Gavin Van De Walle, MS, RDN HerbClip review HC 032122-666, June 15, 2021). 
  2. Long COVID rehab for Neuropsychiatric symptoms: Emotional regulation, Mindfulness, Behavioral activation. Sacks-Zimmerman A, et al. Rehabilitation of Neuropsychiatric Symptoms in Patients With Long COVID: Position Statement [published online ahead-of-print, 2022 Oct 20]. Arch Phys Med Rehabil. 2022;104(2):350-354. doi:10.1016/j.apmr.2022.10.001
  3. Stress modulating herbs- Cognitive Deficit post-COVID: Ginkgo biloba special extract EGb 761 has been suggested as a remedy to alleviate cognitive post-COVID-19 symptoms. Zifko UA, et al. Alleviation of Post-COVID-19 Cognitive Deficits by Treatment with EGb 761®: A Case Series. Am J Case Rep. 2022;23:e937094. Published 2022 Sep 26. doi:10.12659/AJCR.937094
  4. Anosmia and Ageusia: Post-viral olfactory dysfunction (PVOD) is defined as the persistence of olfactory disturbances after a viral infection of the upper respiratory tract, even after the symptoms of upper respiratory tract inflammation have disappeared. The loss of the sense of taste is now well-known as one of the major symptoms of COVID-19. Taste dysfunction is observed in almost 50% of COVID-19 patients. ACE2, one of the receptors the virus binds to enter the cells, is expressed in the oral cavity. Smell training is one of the methods used in facilitating recovery of the olfactory sense, and it uses essential oils of lemon, rose, clove, and eucalyptus. Koyama, S. et al. Possible Use of Phytochemicals for Recovery from COVID-19-Induced Anosmia and Ageusia. Int. J. Mol. Sci. 2021, 22, 8912. ijms22168912
  5. Fatigue: Ginseng Radix et Rhizoma—a popular and effective traditional Chinese medicine—has shown clinical anti-fatigue effects. Zhou X, et al. Anti-fatigue effect from Ginseng Radix et Rhizoma: a suggestive and promising treatment for long COVID. Acupuncture and Herbal Medicine. 2022 Jun;2(2):69–77. doi: 10.1097/HM9.0000000000000033. Epub 2022 Jul 8. PMCID: PMC9407182.
  6. Role of Acupuncture for Long COVID: There is published evidence of acupuncture helping long COVID patients. 1) Williams JE, Moramarco J. The Role of Acupuncture for Long COVID: Mechanisms and Models. Med Acupunct. 2022;34(3):159-166. doi:10.1089/acu.2021.0090; 2) Ren M, et al. The role of acupuncture and moxibustion in the treatment, prevention, and rehabilitation of patients with COVID-19: A scoping review. Integr Med Res. 2022;11(4):100886. doi:10.1016/j.imr.2022.100886.

IM is an area of active investigation that needs further research. Given the diversity and heterogeneity of pathogenic mechanisms underlying long COVID, there is a clear need for individualized therapeutic approaches for each patient. There is an urgent need to utilize resources in the field of IM to help mitigate and resolve suffering in this subset of patients.

Dr. Lara-Marquez is the Past-Chair and current member of the Integrative Medicine Committee of the AAAAI, a volunteer position. Her views are her own. Dr. Lara-Marquez has no conflicts of interest to report.

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