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Understanding Long Covid (LC):

Symptoms, Risk Factors, and Prevention Strategies



Symptoms of Long COVID (LC) include brain fog, fatigue, heart palpitations, post-exertion malaise, fever, shortness of breath, cough, chest pain, headache, sleep problems, pins-and-needles feelings, change in smell or taste, depression or anxiety, diarrhea, stomach pain, joint or muscle pain, rash, or changes in menstrual cycle. LC may last months to years with periods of improvements and exacerbation. The condition is similar to ME/CFS (myologic encephalomyelitis/chronic fatigue syndrome) that may occur after other viral infections. According to the CDC, it is estimated that as many as 19% of patients in the US who have had COVID-19 may experience Long COVID symptoms. However, this percentage could be considerably higher due to potential underreporting of COVID-19 cases.


Risk Factors

Research points to a combination of factors that may increase risk of developing LC, including ongoing inflammation, micro clots, reactivation of latent viruses such as Epstein-Barr virus, direct organ damage by SARS-CoV-2 virus, and triggering of an auto-immune process. Additionally, pre-existing stress and depression seems to increase the risk, with younger patients, women, and racial/ethnic minorities being more likely to be affected by LC. The underlying pathology is thought to be a dysfunctional cellular metabolic system, with an inability to restore energy on the cellular level, leading sufferers to use the inefficient lactic acid system for energy with minimal exertion or activity.



COVID vaccines work well to prevent serious illness from the virus by decreasing the spread of the virus throughout the body and decreasing the chance of experience generalized inflammation and damage that increase risk of developing long COVID. While natural infection does offer some protection, the effect on immunity is not always adequate, which is why the vaccine can more consistently provide sufficient protection. Furthermore, each case of COVID infection can elicit new Long COVID or make it more severe.



There is no known treatment of LC, thus the best strategy is prevention. One should avoid infections and re-infections and take steps to decrease COVID severity by employing immunization, mitigation, and therapeutic strategies. Numerous studies have demonstrated that COVID vaccines and boosters decrease COVID incidence, severity, and development of LC. Many of the risk factors for long COVID cannot be easily changed, but vaccinations are a decision that can be taken by anyone.


Management: Pacing

Experts recommend using “pacing”, an adaptive technique for physical and mental activity that is based on balancing short bouts of activity with sufficient rest periods. The goal is to avoid over-exertion and exhaustion that leads to setbacks. Individuals can monitor their status and progress by employing heart rate biofeedback pacing (HRBP), timers, and switching between activities that use different muscle groups or body systems. One starts at a low level and increases different activities as tolerated, utilizing specific and consistent plans for performing the activities so that they are less dependent on how one is feeling on a given day. Importantly, pacing helps maintain a sense of control, decreasing fear and anxiety, which in turn helps avoid setbacks.



In addition to COVID vaccines, taking Paxlovid (nirmatrelvir/ritonavir) and metformin at the onset of a COVID infection can decrease the risk of developing LC. Paxlovid works by decreasing viral replication, while metformin is thought to decrease inflammation. Both medications require a prescription.


Therapeutic Strategies

There is no known treatment for LC, but several therapeutic modalities have been tried off-label to help with various symptoms; most medications are only available by prescription.

  • Low dose naltrexone (LDN) to help with energy, concentration, and pain; Naltrexone doses of 1-3 mg need to be compounded by special pharmacies.

  • Amitriptyline to help with sleep disturbances and headaches.

  • Gabapentin and other anti-seizure medications to help with pain, numbness, and neurological symptoms.

  • Salt/fluid intake, compression stockings, midodrine, fludrocortisone, and/or beta-blockers to help with postural orthostatic tachycardia syndrome (POTS)

  • Fiber and probiotics to help with gastrointestinal dysregulation.

  • Pulmonary rehabilitation, autonomic conditioning therapy (including breathing therapy), and cognitive rehabilitation.

  • CoQ10 (OTC) to support mitochondrial function in cellular energy production.

  • Anti-oxidant supplements to help decrease systemic inflammation.


Health Advisory

Check with your doctor, pharmacist, and the rest of your health team on employing strategies to decrease the risk of developing or managing Long COVID.

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