Many people who have fought off Covid-19 have been left with lasting symptoms. How can pharmacy teams support people who may still be suffering with the effects of the virus weeks, if not months, later?
Some nine months after Covid-19 was declared a global pandemic – yes its really only been that long – it still hasn’t left the headlines, and it seems that for some people the health implications of the virus itself are lingering too.
Approximately 10 per cent of people who have had Covid-19 may still be experiencing symptoms more than three weeks after infection, and some 60,000 people could still be suffering from so-called long-Covid symptoms after more than three months, according to the NHS.
Long-Covid is defined as the signs and symptoms that develop during or after contracting Covid-19 that continue for more than 12 weeks and are not explained by alternative diagnosis, according to new guidance commissioned by NHS England and published in October 2020 by the National Institute for Health and Care Excellence (NICE).
Common symptoms include muscle aches, headaches, joint and chest pain and fatigue, and these symptoms can appear in clusters and change over time. More serious long-term complications appear to be less common, but have also been reported and include cognitive, respiratory and neurological issues.
If someone suspects they have long-Covid and have severe or long-lasting symptoms, pharmacy teams can refer them to a GP, who can help to ruled out any other possible underlying causes for symptoms before advising on accessing secondary care services, where needed.
For milder symptoms, pharmacy teams can be on hand with practical advice and over-the-counter product recommendations to help ease them, as well as offering advice, support and signposting to customers with anxieties about the lasting effects. See Your Covid Recovery.
Dr Michael Dixon, chair of the College of Medicine, says that management advice for fatigue is often derived from knowledge of post-viral myalgic encephalomyelitis (ME). “For chronic tiredness, light aerobic exercise is a good idea, preferably out in the fresh air, or doing Pilates or yoga,” he says. “But it is important that people don’t push themselves too hard. They should also minimise stress, even everyday pressures that cause frustration.”
According to Dr Sarah Brewer, a registered GP working in nutritional medicine, customers should adopt a regular sleep pattern, aiming to rise and go to bed at the same time each day. “Avoid using screens in the evening, if possible, as these emit blue light that can suppress melatonin hormone secretion and interfere with sleep onset,” she says. “Eat little and often to maintain blood glucose levels, but avoid overly starchy or sweet foods. Carbohydrates trigger the release of insulin to lower blood sugar, and this can lead to an energy slump a couple of hours after eating if sugars swing too low. It’s also important not to skip meals such as breakfast, even if you don’t feel hungry.”
For a fever that keeps flaring up and down, Dr Nisa Aslam, a GP in the London borough of Tower Hamlets, recommends taking paracetamol every four to six hours and staying well hydrated.
Dr Brewer adds that ensuring the room temperature is comfortable (e.g. between 18 and 24°C). “Layer up with clothes that you can take off and put on again as needed,” she says. “If feeling cold, use a hot water bottle or heat pack, wear thick socks, gloves, hat – even indoors. If hot, use a cool pack, keep a fan handy and have a lukewarm shower.”
Dr Aslam says Covid coughs can linger for some time. “For symptomatic relief, try a hot honey and lemon drink – honey has anti-microbial properties,” she says. “Customers can buy cough sweets or cough syrups. Steam inhalation helps with a cough and blocked nose by loosening mucus. This involves sitting with your head over a bowl of hot water, placing a towel over your head, closing your eyes and breathing in deeply. If this feels risky in terms of getting a burn or being scalded, customers can buy a steam inhalation device or machine.”
Dr Dixon also suggests breathing exercises. “Concentrate on abdominal breathing rather than thoracic breathing, which is less effective at getting oxygen into the blood,” he says. “If a customer has reflux, which can affect breathing and make coughing worse, they could try antacids or proton pump inhibitors (PPIs).”
Loss of taste/smell
Rebecca McManamon, registered dietitian and BDA spokesperson, says an absence or change in taste and smell perception can increase the risk of malnutrition. “Cold food may be easier to manage, and sauces and marinades may help, or even foods you don’t usually like may be more pleasant,” she says. “But it can be trial and error. A palate cleanser, such as a lemon or lime drink, or food flavoured with them, may be helpful to trial if food is unpleasant to taste. The charity AbScent has helpful resources on their website, including discussions around smell training for those with long-term symptoms.”
Aches and pains
Ongoing pain may affect specific areas of the body (e.g. a headache) or be more generalised. Dr Knut Schroeder, GP and founder and director of Expert Self Care Ltd, recommends trying paracetamol and/or ibuprofen and taking it easy when pain flares up, but he says customers should speak to their GP if they are concerned. Discussing the different analgesic options available, such as tablets, patches and gels, depending on the customer’s needs and preferences can be helpful. “Balance your need for rest with the need to get on with everyday tasks,” Dr Schroeder adds. “Focus on things you can easily do.”
Dr Brewer suggests adding magnesium flakes to a warm bath to relax and ease tired, aching muscles. “If pain is localised, rubbing in a CBD (cannabidiol) balm can help,” she says. “Some people find CBD by mouth helpful, but advise customers to check with their doctor if they are on any prescribed medication as interactions can occur. Ensure they’re drinking sufficient fluids, as even mild dehydration can contribute to headaches.”
This is characterised by trouble remembering things and processing information, finding it difficult to concentrate and pay attention, or having disorganised thoughts. Often the best way to overcome brain fog is for an individual to pace themselves and balance activity with rest to avoid becoming overwhelmed.
Dr Brewer recommends fish oils, which are traditionally considered to be ‘brain food’. “Fish oils supply the long-chain omega-3 fats needed for optimum brain function and also reduce inflammation, which may be involved in brain fog and difficulty concentrating,” she says. “Aim to eat at least two portions of fish per week, of which one is oily or, if you don’t like eating fish, take a daily omega-3 supplement (fish or from vegan sources such as algae). B-group vitamins are vital for healthy thought processes, especially B1, B6, B12 and folic acid. Magnesium also contributes to normal psychological function.”
It’s natural to have a low mood after any illness, and Covid-19 can be particularly draining on the body and mind. Eating well, not drinking too much alcohol, keeping physically active and maintaining contact with family and friends – either online, over the phone or in person, where suitable – may help.
It is also widely thought that Covid-19 can trigger anxiety and depression, or make existing problems worse. “Recovery can take its toll on those already suffering psychological issues,” says Naresh Rallmil, Numark service development pharmacist. “Customers can be advised on mental health issues or referred to their GP practice if required.”
Diet and lifestyle risks
Obese or overweight people seem more likely to experience Covid-19 complications. In July 2020, Public Health England estimated that having a BMI of 35-40 could increase a person’s chances of dying from Covid-19 by 40 per cent, while a BMI greater than 40 could increase the risk by 90 per cent. This may be because obesity increases inflammation in the body, and fat in the lungs may affect how the lungs deal with the virus.
Studies have also found that more than 80 per cent of hospital patients with Covid-19 lack vitamin D. “During the winter months, the general advice from the Department of Health and Social Care is to take 10 mcg vitamin D daily (October-March),” says registered dietitian and BDA spokesperson Rebecca McManamon. “This is sensible advice regardless of Covid-19 to prevent deficiency. Calcium and vitamin D shouldn’t be given together unless advised by a doctor or dietitian.”
Dr Sarah Brewer, a registered GP working in nutritional medicine, says good intakes of vitamins A, E, and D are linked to fewer respiratory complaints, according to a recent study published in the journal BMJ Nutrition Prevention & Health. “While diet should always come first, this study found that only vitamin D from supplements rather than food provided protection against respiratory complaints,” she says. “This is most likely because it is difficult to obtain significant amounts of vitamin D from diet alone, unless you eat a lot of oily fish. Some studies have found that people with sufficient levels of vitamin D are 54 per cent less likely to develop coronavirus symptoms, 13 per cent less likely to develop severe illness, 46 per cent less likely to need intubation and also have a 52 per cent lower risk of dying from Covid-19 after hospitalisation than those who are vitamin D deficient, after taking other known factors into account.”
Expand your knowledge
See TM's feature on the debilitating effects of long-Covid for further information about what long-Covid is and community pharmacy's role in its management.