Post COVID-19 Complications And Management

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Supplemental material, sj-pdf-1-jrs-10.1177_01410768211032850 for Symptoms, complications and management of long COVID: a review by Olalekan Lee Aiyegbusi, Sarah E Hughes, Grace Turner, Samantha Cruz Rivera, Christel McMullan, Joht Singh Chandan, Shamil Haroon, Gary Price, Elin Haf Davies, Krishnarajah Nirantharakumar, Elizabeth Sapey, Melanie J Calvert and on behalf of the TLC Study Group in Journal of the Royal Society of Medicine

This course will include an overview of the clinical relationship between HIV and COVID-19, 2 case-based panel discussions on difficult cases in prevention, outpatient care, and inpatient care for COVID-19, including what drugs to use and when, and a discussion on post-COVID-19 complications, including our current understanding of the mechanisms of long-COVID-19.

Since its inception in late December 2020 in China, novel coronavirus has affected the global socio-economic aspect. Currently, the world is seeking safe and effective treatment measures against COVID-19 to eradicate it. Many established drug molecules are tested against SARS-CoV-2 as a part of drug repurposing where some are proved effective for symptomatic relief while some are ineffective. Drug repurposing is a practical strategy for rapidly developing antiviral agents. Many drugs are presently being repurposed utilizing basic understanding of disease pathogenesis and drug pharmacodynamics, as well as computational methods. In the present situation, drug repurposing could be viewed as a new treatment option for COVID-19. Several new drug molecules and biologics are engineered against SARS-CoV-2 and are under different stages of clinical development. A few biologics drug products are approved by USFDA for emergency use in the covid management. Due to continuous mutation, many of the approved vaccines are not much efficacious to render the individual immune against opportunistic infection of SARS-CoV-2 mutants. Hence, there is a strong need for the cogent therapeutic agent for covid management. In this review, a consolidated summary of the therapeutic developments against SARS-CoV-2 are depicted along with an overview of effective management of post COVID-19 complications.

The clinical management of patients with COVID-19 who are in the intensive care unit should include treatment with immunomodulators, and, in some cases, the addition of remdesivir. These patients should also receive treatment for any comorbid conditions and nosocomial complications. For more information, see Critical Care for Adults and Therapeutic Management of Hospitalized Adults With COVID-19.

MIS-C and multisystem inflammatory syndrome in adults (MIS-A) are serious postinfectious complications of SARS-CoV-2 infection. For more information on these syndromes, see Therapeutic Management of Hospitalized Pediatric Patients With Multisystem Inflammatory Syndrome in Children (MIS-C) (With Discussion on Multisystem Inflammatory Syndrome in Adults [MIS-A]).

As per WHO generally people will take an incubation period of 10 to 14 days to recover fully, and sometimes more. Mild to moderate case of COVID-19 will recover in about 14 days. Sometimes COVID-19 symptoms can remain for more than 20 days up to 45 days. Due to long term effect of coronavirus, patients can develop post-COVID complications.

Most people infected with COVID-19 infection get better within 10 days of illness. People when continue to experience mild symptoms post recovery called as Post Covid Syndrome or Long Covid, these people may experience post COVID conditions and also develop long-term complications that affect the organs.

Elderly old age group people and people having serious medical conditions such as diabetes, immunodeficiency disorders, cancers or chronic diseases are at the risk of developing post COVID complications.

As per recent data of SARS-CoV-2 survivors, 30-40% of who had secondary infections, survivors of acute COVID-19 infection may be at increased risk of infections with bacterial, fungal infections or other complications. However, these secondary infections do not explain the persistent and prolonged consequence of a previous infection in post-acute COVID-19.

Coronavirus can cause long-lasting damage to the immune system, which can affect organs and changes, particularly in the lungs may last for long, in this conditions post COVID care is very important to avoid further reinfection or complications.

Multidisciplinary collaboration is essential to provide integrated outpatient care to survivors of acute COVID-19 in COVID-19 clinics. Depending on resources, prioritization may be considered for those at high risk for post-acute COVID-19, defined as those with severe illness during acute COVID-19 and/or requirement for care in an ICU, advanced age and the presence of organ comorbidities (pre-existing respiratory disease, obesity, diabetes, hypertension, chronic cardiovascular disease, chronic kidney disease, post-organ transplant or active cancer). The pulmonary/cardiovascular management plan was adapted from a guidance document for patients hospitalized with COVID-19 pneumonia76. HRCT, high-resolution computed tomography; PE, pulmonary embolism.

Despite initial theoretical concerns regarding increased levels of ACE2 and the risk of acute COVID-19 with the use of RAAS inhibitors, they have been shown to be safe and should be continued in those with stable cardiovascular disease126,127. Instead, abrupt cessation of RAAS inhibitors may be potentially harmful128. In patients with ventricular dysfunction, guideline-directed medical therapy should be initiated and optimized as tolerated129. Withdrawal of guideline-directed medical therapy was associated with higher mortality in the acute to post-acute phase in a retrospective study of 3,080 patients with COVID-19 (ref. 130). Patients with postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia may benefit from a low-dose beta blocker for heart rate management and reducing adrenergic activity131. Attention is warranted to the use of drugs such as anti-arrhythmic agents (for example, amiodarone) in patients with fibrotic pulmonary changes after COVID-19 (ref. 132).

Standard therapies should be implemented for neurologic complications such as headaches, with imaging evaluation and referral to a specialist reserved for refractory headache166. Further neuropsychological evaluation should be considered in the post-acute illness setting in patients with cognitive impairment. Standard screening tools should be used to identify patients with anxiety, depression, sleep disturbances, PTSD, dysautonomia and fatigue76,141.

Endocrine manifestations in the post-acute COVID-19 setting may be consequences of direct viral injury, immunological and inflammatory damage, as well as iatrogenic complications. Pre-existing diabetes may first become apparent during the acute phase of COVID-19 and can generally be treated long term with agents other than insulin, even if initially associated with DKA. There is no concrete evidence of lasting damage to pancreatic β cells188. Although some surveys have shown ACE2 and transmembrane serine protease (TMPRSS2; the protease involved in SARS-CoV-2 cell entry) expression in β cells189, the primary deficit in insulin production is probably mediated by factors such as inflammation or the infection stress response, along with peripheral insulin resistance188. So far, there is no evidence that COVID-19-associated diabetes can be reversed after the acute phase, nor that its outcomes differ in COVID-19 long haulers. COVID-19 also presents risk factors for bone demineralization related to systemic inflammation, immobilization, exposure to corticosteroids, vitamin D insufficiency and interruption of antiresorptive or anabolic agents for osteoporosis190.

Moreover, it is clear that care for patients with COVID-19 does not conclude at the time of hospital discharge, and interdisciplinary cooperation is needed for comprehensive care of these patients in the outpatient setting. As such, it is crucial for healthcare systems and hospitals to recognize the need to establish dedicated COVID-19 clinics74, where specialists from multiple disciplines are able to provide integrated care. Prioritization of follow-up care may be considered for those at high risk for post-acute COVID-19, including those who had severe illness during acute COVID-19 and/or required care in an ICU, those most susceptible to complications (for example, the elderly, those with multiple organ comorbidities, those post-transplant and those with an active cancer history) and those with the highest burden of persistent symptoms.

They may be more likely to have pregnancy complications than pregnant women without COVID-19. These complications may be related to high blood pressure, heavy postpartum bleeding, and other infections. This is especially true for pregnant women with moderate and severe illness.

Currently there is a backlog of surgical procedures that have been delayed but are necessary to improve the health and quality of life of our patients. Although there is increasing information to address the timing of surgery after COVID-19 infection, studies continue to lag behind the emerging variants and the likelihood that vaccinated patients have a lower a risk of postoperative complications as compared to unvaccinated patients.3 Almost all available data come from study periods with zero to low prevalence of vaccination.

A second U.S. study covering a timeline of patients with a COVID-19 diagnosis and surgery up to May 31, 2021 reviewed 5479 surgical patients following COVID-19 infection. Immunization status was not given but the study period ranged from a time of zero vaccination until a period when about 30% of the US adult population had received at least one vaccination. The results corroborate the above findings and report higher postop complications of pneumonia and respiratory failure at 0-4 weeks and continued higher postoperative pneumonia complications 4-8 weeks post PCR diagnosis.7 59ce067264

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