Michael McKendall, MS, PharmD

With the recent increase in vaccine distribution and reduction of new cases, a gleam of hope can be seen among health care workers that the worst of COVID-19 is behind us. However, research has proven that the effects of COVID-19 may continue to challenge patients and the health care field even after the spread of the virus is well controlled. Though some may recover quickly from the virus, lingering symptoms continue to be evident for weeks and even months after infection for others. Often referred to as “long COVID” patients or “long-haulers,” these patients continue to experience symptoms of illness far past the acute phase of this viral disease.

“Long COVID” is not a new mystery, and researchers have been attempting to track and understand the recovery timeline of patients with COVID-19 since the outbreak of the virus. From April 21, 2020 to May 29, 2020, researchers in Italy surveyed patients regarding their symptoms following discharge from hospitalization.

 At a mean of 60.3 days following the onset of COVID-19 symptoms, only 12.6% of the 143 patients surveyed were completely free of their symptoms. A large portion of those patients continued to experience symptoms including fatigue (53.1%), dyspnea (43.4%), and joint pain (27.3%). These findings align with those of other studies. The results of one study conducted on 1733 discharged patients with COVID-19 reported that 76% of patients continued to experience symptoms after 175 to 199 days post symptom onset.2This study also highlighted fatigue as a commonly persistent symptom, with 63% of those symptomatic patients complaining of fatigue or muscle weakness.

Though patients with more severe cases of COVID-19 seem to be more prone to developing extended complications, the lingering symptoms of the disease are not just seen among those who were hospitalized. Patients who experienced a milder case of acute COVID-19 illness have also been shown to suffer from this phenomenon. In July of 2020, the CDC released in its 

 the results of a multistate telephone survey conducted on individuals over 18 years of age who had a positive COVID-19 test result in an outpatient setting.3 These interviews were conducted 14 to 21 days after the test date. Among the 292 respondents, 35% reported not returning to their usual state of health. Cough, fatigue, and shortness of breath were the top 3 most common symptoms that persisted among these patients, respectively. Though fatigue seems to be the most prevalent symptom, reported symptoms also include difficulty concentrating (“brain fog”), depression, heart palpitations, and acute kidney injury, among many others.

Finding the cause of “long COVID” and understanding why some individuals recover more quickly than others continues to be a challenge that we hope to better understand with further research. Possible explanations range from inflammatory and immune reactions to mental health issues such as post-traumatic stress.

The unusually prolonged symptoms associated with COVID-19 present a number of challenges to health care systems across the world. Patients initially showing improvement with treatment during the acute phase of this disease are at times decompensating following discharge, leading to readmission.

One study following nearly 2000 patients with COVID-19 in the Veterans Affairs health care system found that 19.9% of patients were readmitted within 60 days of discharge.

 The most common readmission diagnosis was COVID-19, followed by sepsis, pneumonia, and heart failure. This high readmission rate exceeded those of non-COVID pneumonia and heart failure patients within the first 10 days of discharge. In November of 2020, the CDC released a report calling attention to the elevated readmission rate among patients with COVID-19.

In a cohort of 106,543 patients discharged after a COVID-19 hospitalization, 9% of patients experienced at least 1 readmission to the same hospital within 2 months. Of these readmissions, 10.1% occurred in relatively young patients, ranging from ages 18 to 40. Readmissions were often due to diseases of respiratory, circulatory, and digestive diseases. This further highlights the fact that COVID-19 is not strictly a respiratory disease, but rather a multi-system disease.

Though the full financial impact on health care systems is not yet known in this ongoing pandemic, “long COVID” will undoubtedly be a factor in extending that impact. Many patients who may have otherwise not required medical treatment will now seek assistance in addressing these lingering symptoms. Just as they did when the outbreak of COVID-19 began, hospital systems must adapt to these new obstacles. One strategic attempt to tackle this issue for some health care systems is the establishment of “Post-COVID” clinics.

 These programs range from in-person or telehealth visits to call lines specifically for “long-haulers” where they direct patients to appropriate specialty services for symptom-specific treatments. There has been an increase in these clinics across the United States, and they may be the appropriate solution for many patients who seek help and answers for their “long COVID” symptoms.

 Pharmacists as a whole are in a unique position due to the complexity of patients and areas of care they are involved in.

Retail pharmacists are readily accessible to the general public and are often the first health care professional patients with “long COVID” may seek answers from. With the ramping up of vaccine distribution, the number of direct patient interactions among these pharmacists with their patients will be substantially increased. Anticipation of encountering patients with “long COVID” is a beneficial idea. Being aware of local “post-COVID” programs to refer them to could make the pharmacist a valuable resource to these patients, many of whom may not be aware of these programs.

Pharmacists involved in transitions of care could be a valuable resource for patients with COVID-19 being discharged from the hospital. Whether in person or through the phone, these pharmacists can help ensure patients are well educated on any new or chronic medications as well as reiterate the importance of monitoring symptoms after discharge. Keeping in contact with these patients even after discharge could be helpful in ensuring proper health care management. This will hopefully serve as a way to address further complications early, thus avoiding the need for readmission to the hospital.

Keeping up to date with further research and possible treatments for “long COVID” is one skill all pharmacist should attempt to work toward. Pharmacists who are aware of new and improved strategies for the treatment of “long COVID” can serve as an important tool in helping to ensure treatments within their health care system are current, safe, and effective.

Dustin Becnel, PharmD, is a PGY-1 pharmacy resident at East Jefferson General Hospital. 

Michael McKendall, MS, PharmD, is the director of pharmacy services at East Jefferson General Hospital.

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 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. 

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3. Tenforde MW, Kim SS, Lindsell CJ, et al. Symptom duration and risk factors For delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network – United States, March-June 2020. 

4. Centers for Disease Control and Prevention (CDC). Long Term Effect of COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects.html. Accessed March 10, 2021.

5. Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. 

6. Donnelly JP, Wang XQ, Iwashyna TJ, Prescott HC. Readmission and death after initial hospital discharge among patients with COVID-19 in a large multihospital system. 

 2021;325(3):304–306. doi:10.1001/jama.2020.21465.

7. Lavery AM, Preston LE, Ko JY, et al. Characteristics of hospitalized COVID-19 patients discharged and experiencing same-hospital readmission - United States, March-August 2020. 

8. Edwards E. Inside ‘post-Covid’ clinics: How specialized centers are trying to treat long-haulers. 

. March 1, 2021. https://www.nbcnews.com/health/health-news/inside-post-covid-clinics-how-specialized-centers-are-trying-treat-n1258879.html. Accessed March 10, 2021.

Articles

Often referred to as “long COVID” patients or “long-haulers,” these patients continue to experience symptoms of illness far past the acute phase of this viral disease. 