Managing COVID-19 post viral fatigue syndrome, by Charles W Lapp and Joseph F John  in Fatigue: Biomedicine, Health & Behavior, Feb 22, 2021

Article abstract:

In online surveys, over 50% of persons who contract COVD-19 experience symptoms lasting longer than 90 days [Pelanti S, Grassi E, Markris N, et al. J Psych Res. 2020. doi:10.1016/j.jpsychires.2020.08.008]

Despite an estimated 3 million Americans being affected by COVID post-viral fatigue, there has been little discussion about the care of these patients, most of whom report feeling unsupported or dismissed by their providers [Amitay O, Komaroff AL. The Guardian, 20 Aug 2020].

This article points out the similarity between this post-viral fatigue syndrome and Chronic Fatigue Syndrome (ME/CFS) or Systemic Exertion Intolerance Disease (SEID), and offers evidence-based suggestions for management.

Recommendations for management

One year has elapsed with the COVID-19 pandemic, and it appears that this novel virus is capable of causing a syndrome similar to ME/CFS, as many other infections have done in the past. There is currently no Standard of Care for the management of such Long Haulers, so our recommendations are based on past experiences with SARS, expert opinion, our experience with ME/CFS, as well as expanding knowledge of COVID-19 illness. Here, we offer a sequence for diagnosis and treatment based primarily on our experience treating ME/CFS.

First, a rigorous history and physical examination should commence care. Second, routine testing should be performed to establish a baseline and to rule out sequelae of the disease that might produce chronic fatigue (see Table 2). Third, patients should be encouraged to rest frequently and aggressively and to set limits on daily activities so as to avoid exacerbations of their symptoms and post-exertional malaise. Overexertion leads to a prolonged exacerbation of symptoms (known as ‘post-exertional malaise’ or PEM) in persons with ME/CFS, and empirically we know that repeated PEM perpetuates or worsens the illness. Therefore, it is imperative that patients be advised to limit activity and balance activity with adequate rest in order to avoid PEM. Finally, clinicians can address the major issues of sleep disruption, pain, orthostatic symptoms, headache, and other co-morbidities so common in ME/CFS. These symptoms can be managed in the usual manner or referral to specialists.

Pain is very common in ME/CFS but is frequently managed with physical therapies (hot or cold packs, Epsom soaks, massage, topical creams or liniments). In the past few years, low dose naltrexone (0.1–5 mg daily) has proved to be useful for myalgic pain. For more severe pain non-narcotic pain medications such as pregabalin, duloxetine or milnacipran are recommended. Opiates – if considered appropriate – might best be prescribed by a pain specialist.

Orthostatic symptoms such as lightheadedness, dizziness, upright intolerance, orthostatic hypotension or tachycardia, and even neurally mediated hypotension are common in ME/CFS. Management begins with volume expansion (drinking at least 64 ounces of water or non-caffeinated beverage daily and ingesting extra salt – if not hypertensive). Tachycardia may require a beta-blocker for symptomatic relief. If orthostasis is not improved by volume expansion (including parenteral fluids) consider consultation by cardiology.

Treating fatigue requires novel approaches as fatigue may respond to agents that clinicians may not regularly employ in their routine practices. This constellation may involve caffeinated drinks, low dose naltrexone, the use of stimulants including modafinil and methylphenidate, and other agents including antivirals. Other modalities including a wide variety of non-prescription supplements may help optimize the patient’s health. The following supplements are recommended based on available evidence:

• Vitamin C may shorten or lessen the symptoms of the common cold (frequently caused by coronaviruses), and benefit the immune system. Studies are underway looking at the potential of Vitamin C in more severe cases of COVID-19. A dose of 500 mg per day is generally safe, with a maximum of 2000 mg daily.

• Vitamin D3: Research has shown that countries whose population had lower levels of 25-OH Vitamin D had a higher incidence of COVID, and individuals with higher levels of 25-OH Vitamin D at illness onset have a milder course and lower rate of ICU admissions. Consider at least 1000–2000 iu daily to start. Because Vitamin D is fat soluble, individuals with a high body mass will likely require more.

• Echinacea increases NK Cell Activity thereby supporting, if needed, the body’s antiviral system. It has been used to prevent upper respiratory tract infections. The usual dose is 300 mg daily, and drug holidays are recommended to avoid stimulating autoantibodies. Echinacea is contraindicated in RA, lupus erythematosus, multiple sclerosis, and other conditions associated with autoantibodies.

• B12 and folate. These serum levels tend to be low in persons with ME/CFS, suggesting that supplementation might be beneficial. Methyl-cobalamin is taken as 1000 mcg daily along with 400–1000 mcg daily of methyl-folate.

• CoQ10 also tends to be low in persons with ME/CFS. This is the most ubiquitous cofactor in the human body and supplementation with 100–200 mg daily might benefit metabolism.

• Turmeric (curcumin) is a spice used in curry and mustard. However, it possesses potent antioxidant activity and reduces inflammation. It is particularly useful for mild muscle and joint aching, but is contraindicated in pregnancy due to its ability to cause uterine contractions. The usual dose is 500 mg twice daily.

If for no other reason, supplementation may enhance one’s innate and adaptive immune response, suppress inflammation, and reduce oxidative stress. The literature suggests the use of Vitamins A, D, C, B12, B6 and folate; micronutrients zinc, iron, selenium, copper; and omega-3 fatty acids as essential. In COVID-19, Vitamin D, selenium, and iron seem to be most important.

Although their effect on COVID-19 is controversial, current guidelines recommend continuation of therapy with ACE inhibitors (ACEI) or angiotension receptor blockers (ARBs).

See the full article for:

Overview & testing of COVD-19

Post-viral & post-COVID fatigue

Post-Viral Fatigue Syndrome (PVFS) versus Chronic Fatigue Syndrome (ME/CFS)

Table 1. Criteria for the Clinical Diagnosis of ME/CFS

Table 2. Clinical and Laboratory Testing of COVID-19 Long Haulers

Online resources for long haulers and ME/CFS