Patients need a carefully designed but flexible long haul COVID treatment protocol tailored to their particular symptoms and needs
As the COVID-19 pandemic wanes, the number of survivors with long-hauler’s syndrome, and patients in need of a long haul COVID treatment protocol, continues to rise at an unexpected rate. The CDC defines long-hauler’s syndrome — also known as PASC (post-acute sequelae of SARS-CoV-2) or long COVID — as a wide range of new, returning or ongoing health problems people experience after first being infected with the SARS-CoV-2 virus.[i]
As we learn more about post-COVID syndrome, however, the definition has been refined to be more accurate and useful:[ii]
- Subacute or ongoing COVID-19 (post-acute COVID-19 syndrome): symptoms continuing beyond four weeks from acute infection, up to 12 weeks.
- Post-acute sequelae of COVID-19 (PASC): symptoms persisting beyond the four weeks after acute infection.
- Post-COVID-19 syndrome (long COVID, long-hauler’s syndrome): chronic ongoing COVID-19 symptoms beyond 12 weeks from acute infection.
A widespread syndrome
While the CDC tracks the prevalence of 26 common post-COVID conditions affecting a significant body system,[iii] more than 50 long-term effects, particularly fatigue, headache, attention disorders, shortness of breath and hair shedding, are now attributed to long-hauler’s syndrome.[iv]
Recent studies show how widespread the syndrome is. The global prevalence of post-COVID syndrome four months after the infection is now estimated at 49% of all patients. About 54% of hospitalized patients had long-hauler symptoms; about 34% of non-hospitalized patients had symptoms.
Among those who were hospitalized, only 26% fully recovered after five months,[v] and nearly half still had symptoms one year later.[vi] Those who needed mechanical ventilation were 58% less likely to heal fully; obese people were half as likely to recover fully.[vii] At the two-year mark, 55% of hospitalized patients had at least one COVID-19 symptom, compared to 68% six months after infection. Patients generally had poorer health two years later and still experienced pain, fatigue, problems with sleeping and mental health issues. They went to a doctor more often, had ongoing difficulty exercising, and experienced poor quality of life.[viii]
Clearly, long-hauler’s syndrome is common and likely to be with us for a prolonged period of time.[ix]
Mild disease, severe consequences
Although those hospitalized for COVID-19 are at greater risk of long-hauler’s syndrome, moderate, mild or even asymptomatic illness can also lead to debilitating post-COVID symptoms.
A recent study using U.S. health insurance records suggests that over 75% of people with long-hauler’s syndrome were never hospitalized for COVID. After the acute illness was over, nearly 25% of these patients had ongoing respiratory symptoms, chiefly shortness of breath and cough; 17% had fatigue, brain fog, and exhaustion that got worse with physical or mental activity. Abnormal heartbeats and sleep disorders were also common.[x]
Eighteen months after hospitalization, many patients report feeling fully recovered, yet are still affected — they are sicker than they feel. A recent study showed that among these patients, performance in a six-minute walk test worsened, declining on average from 387 to 310 meters. In the same period, walking distance for outpatients improved from 391 to 500 meters.[xi]
An international study showed that fatigue is the most common long-hauler’s syndrome, affecting 80% of all patients. Post-exertional malaise affects 73%, cognitive dysfunction affects 58%, sensorimotor symptoms such as loss of smell affect 56%, headache affects 54%, and memory issues affect 51%.[xii] A year after infection, common persistent symptoms include fatigue (reported by 82% of patients), brain fog (written by 67%), and headache (reported by 60%).[xiii]
Practitioners need to be aware that any patient with one or more of a wide range of new symptoms could be suffering from long-hauler’s syndrome, even if they had only mild COVID-19. Asymptomatic COVID-19 should be suspected if a patient reports new symptoms associated with long-hauler’s syndrome but wasn’t noticeably ill in recent months. All these patients must be taken earnestly, thoroughly evaluated, and given treatment protocols targeted to their symptoms.
Long haul COVID treatment protocols for specific symptoms
In an earlier article,[xiv] I discussed a multipronged approach for treating patients by calming systemic inflammation via dietary modifications, nutritional support, resolving gut dysbiosis and intestinal permeability, and improved sleep, while also dealing with underlying systemic inflammation that slows recovery.
In addition to the basic protocols discussed in my previous article, some patients will need additional support such as a long haul COVID treatment protocol to build immunity and manage specific symptoms.
Fatigue and sleep disturbances
Fatigue and sleep disturbances continue to be among the most common long COVID symptoms.
The debilitating fatigue reported by many long-hauler patients may be related to virus-triggered damage to the mitochondria. The infection makes the mitochondria go into the danger cell response, where their activity switches from energy production for an activity to energy production to support the immune system. The switch in cellular energy production favoring immune defense leaves little energy for other functions and leads to persistent fatigue.[xv]
To treat the danger cell response and help restore better mitochondrial function, I’ve found that this supplement protocol is helpful:
- B vitamins: 60 mg/day
- CoQ10: 300 mg/day
- Acetyl-L-carnitine: 1,000 mg/day
- NMN (nicotinamide mononucleotide), a precursor to NAD+: 200 mg/day
- Alpha-lipoic acid (ALA): 600 mg/day
- NAC/liposomal glutathione: 500 mg/day
- Magnesium: 200 mg/day
- Zinc: 40 mg/day
- Selenium: 200 mg/day
- Vitamin C: 2000 mg/day
Another possible cause of ongoing fatigue is the presence of persistent SARS-CoV-2 virus and RNA fragments in the gut that release the virus and virus particles into the circulation through increased intestinal permeability.[xvii]
Similarly, viral ghosts — persistent fragments of the virus (RNA proteins) that linger on after infection — may continuously activate the immune system, causing fatigue and brain fog, but not symptoms of acute infection.[xviii]
To treat a possible gut reservoir of the virus and to help eradicate circulating virus traces, I recommend Dr. Rob’s 7R Action Plan gut protocol to help resolve gut permeability (see the previous article) and the addition of immune-boosting medicinal mushrooms, including reishi, maitake, lion’s mane, chaga and shiitake.
Insomnia and other sleep disturbances are common in post-COVID patients, leading to persistent fatigue and daytime sleepiness. Post-viral fatigue due to lingering inflammation is common after other severe viral infections, and COVID-19 is probably no different.
In addition, sleep disorders are a common feature of myalgic encephalomyelitis/chronic fatigue syndrome, a condition that has many resemblances to long-hauler’s syndrome. A recent study in the U.K. found that post-COVID fatigue and sleep disturbances didn’t have much relation to depression, anxiety, PTSD or other psychiatric conditions, either preexisting or resulting from having the virus.[xix] In other words, in many cases, sleep disturbances have a physiological, not psychological, basis and may respond well to supplements that support sleep.
In addition to counseling on good sleep hygiene and encouraging rest and patience, I use this protocol to help my patients achieve better sleep:
- L-theanine: 350 mg
- Baikal skullcap: 300 mg
- Lemon balm: 250 mg
- Passionflower: 250 mg
- 5-HTTP: 150 mg
- Melatonin: 3 mg
- Vitamin B6: 10 mg
The supplements should be taken about an hour before the desired bedtime. They help induce sleep without sedation or grogginess the following day, all supported by good evidence. L-theanine, for example, is found naturally in green tea and has been clinically shown to improve overall sleep quality. It supports GABA levels in the brain, increases dopamine and serotonin production, and stimulates sleep-inducing alpha-wave generation.[xx]
For patients experiencing insomnia related to anxiety and depression, I recommend the addition of Baikal skullcap (Scutellaria baicalensis), also known as Chinese skullcap. Flavones found in the roots of this plant include wogonin, which acts on the GABA(A) receptor site, producing anxiolytic effects similar to diazepam.[xxi]
COVID patients who were hospitalized may have insomnia related to the disturbed and disrupted sleep they experienced. Melatonin may help restore their normal sleep/wake cycle and improve sleep quality.[xxii] The usual starting dose is low, 1 to 3 mg taken one hour before the desired bedtime.
Sudden hair shedding (telogen effluvium, or TE) can be a distressing sequel to experiencing COVID-19. Under normal conditions, about 100 hairs a day are usually shed. With TE, many more hairs are shed each day, and the hair may come out in clumps when combed or washed, causing the loss of up to about 50% of all scalp hair.
Ordinarily, about 90% of scalp hair follicles are in the growing stage (anagen). After an acute illness with fever, or just high fever, the follicles can abruptly shift from the growing stage to the resting phase (telogen), causing more hairs than usual to suddenly enter the shedding phase of the hair growth cycle. Significant hair shedding may start 2-3 months after the illness and take about six months to resolve. Pro-inflammatory cytokines released during the infection may trigger hair shedding after COVID-19, but it’s also plausible that drugs administered during the infection are a contributing cause.[xxiii]
For most patients, TE resolves in under six months. Some studies suggest that hair shedding after COVID-19 infection starts sooner, usually at two months, and recovery is faster, taking an average of 2-3 months.[xxiv] For people with long-hauler syndrome, however, the excessive hair shedding can last longer, a condition called chronic telogen effluvium.[xxv]
Supplements to support hair growth, starting when the shedding is first noticed, can be very helpful. I recommend this daily protocol:[xxvi]
- Vitamin A: 1,000 mcg
- Vitamin C: 70 mg
- Vitamin D: 1,000 IU
- Vitamin E: 25 mg
- Biotin: 5,000 mcg
- Pantothenic acid: 100 mg
- Zinc: 30 mg
- Hydrolyzed bovine collagen, Type 1 and Type 3: 250 mg
- Amino acid blend: Glycine 300 mg, L-proline 250 mg, L-lysine HCL 250 mg, NAC 250 mg and L-methionine 50 mg
Controlling the host
You can’t control the virus, but you can control the host. Diet and lifestyle improvements can go a long way to helping patients manage long-hauler symptoms.
Weight loss, if necessary, should be encouraged — we know overweight people are more likely to become seriously ill with COVID-19 and have worse outcomes. Similarly, because people with metabolic dysfunction (obesity, prediabetes and diabetes) are at greater risk for severe acute COVID-19 and later long-hauler syndrome, these patients should be encouraged to achieve the best glycemic control possible.[xxvii]
Practitioners should also know that COVID-19 infection may create new metabolic conditions or unmask existing ones, such as insulin resistance.[xxviii] A May 2022 study found that the risk of diabetes one year after acute COVID-19 infection increases by 40%.[xxix] All post-infection patients, particularly those with long-hauler syndrome, should be assessed for metabolic syndrome, prediabetes and diabetes.
For most long-hauler patients, an anti-inflammatory, plant-forward diet high in fiber and good fats from olive oil, nuts and avocados is beneficial and part of a long haul COVID treatment protocol. I recommend avoiding GPS (gluten, processed foods and sugar) and DNA (drugs, nicotine, alcohol). Because ongoing inflammation can lower the threshold for tolerating some foods and toxins, patients should also be evaluated for food sensitivities and environmental toxins overload.
The SARS-CoV-2 virus enters the lungs and other organs via the angiotensin-converting enzyme 2 (ACE2) receptors.[xxx] The virus destroys the ACE2 enzyme. To enhance the ability to generate ACE2 enzymes, vitamin D supplements, resveratrol, quercetin and curcumin may be helpful.[xxxi]
Other lifestyle changes that may help treat long-hauler syndrome include an individualized home exercise plan stressing strength training to restore lost muscle mass. Stress modification can help improve sleep and overall quality of life. Low-level laser therapy (LLLT), particularly for the vagus nerve, may help with a range of symptoms, including diarrhea. Since every person with the syndrome is unique, patients need a carefully designed but flexible long haul COVID treatment protocol tailored to their particular symptoms and needs.
From my experience with patients suffering from long-hauler’s syndrome, lifestyle, nutrition, supplements and laser all play a valuable role in managing symptoms and putting them on the path to improved health.
ROBERT G. SILVERMAN, DC, DACBN, DCBCN, MS, CCN, CNS, CSCS, CIISN, CKTP, CES, HKC, FAKTR, is a chiropractic doctor, clinical nutritionist, national/international speaker, author of Amazon’s #1 bestseller “Inside-Out Health,” and founder and CEO of Westchester Integrative Health Center. He graduated magna cum laude from the University of Bridgeport College of Chiropractic and has a Master of Science degree in human nutrition. The ACA Sports Council named him “Sports Chiropractor of the Year” in 2015. He is on the advisory board for Functional Medicine University and is a seasoned health and wellness expert on the speaking circuits and in the media. A frequently published author in peer-reviewed journals and other mainstream publications, he is a thought leader in his field and practice. His new book, “Superhighway to Health,” was published in June 2021. He can be reached at drrobertsilverman.com.
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[x] FAIR Health White Paper, Patients Diagnosed with Post-COVID Conditions: An Analysis of Private Healthcare Claims Using the Official ICD-10 Diagnostic Code, May 18, 2022.
[xi] Young I, et al “Reported pulmonary symptoms of post-acute sequelae SARS-CoV-2 infection (PASC) compared to performance on six-minute walk tests” ATS 2022.
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[xxviii] Reiterer M, Rajan M, Gómez-Banoy N, et al. Hyperglycemia in acute COVID-19 is characterized by insulin resistance and adipose tissue infectivity by SARS-CoV-2. Cell Metab. 2021 Nov 2;33(11):2174-2188.e5. doi: 10.1016/j.cmet.2021.09.009. Epub 2021 Sep 16. Erratum in: Cell Metab. 2021 Dec 7;33(12):2484. PMID: 34599884; PMCID: PMC8443335.
[xxix] Xie Y, Al-Aly Z. Risks and burdens of incident diabetes in long COVID: a cohort study. Lancet Diabetes Endocrinol. 2022 May;10(5):311-321. doi: 10.1016/S2213-8587(22)00044-4. Epub 2022 Mar 21. PMID: 35325624; PMCID: PMC8937253.
[xxx] Ni W, Yang X, Yang D, et al. Role of angiotensin-converting enzyme 2 (ACE2) in COVID-19. Crit Care. 2020 Jul 13;24(1):422. doi: 10.1186/s13054-020-03120-0. PMID: 32660650; PMCID: PMC7356137.
[xxxi] Pawar KS, Mastud RN, Pawar SK, et al. Oral Curcumin With Piperine as Adjuvant Therapy for the Treatment of COVID-19: A Randomized Clinical Trial. Front Pharmacol. 2021 May 28;12:669362.