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PubMed This is a summary of 21 peer-reviewed journal articles Updated
Post-Acute Sequelae of SARS-CoV-2

Managing Long COVID Symptoms and Safe Treatments

At a Glance

Long COVID management is individualized: pacing can help prevent post-exertional crashes, POTS symptoms may improve with clinician-supervised fluids, salt, and compression, and every medication or off-label treatment requires careful safety review.

Managing Long COVID—medically called Post-Acute Sequelae of SARS-CoV-2 (PASC) — requires a shift in how many people think about recovery. Unlike a typical illness where you “push through” to get better, recovery from Long COVID often requires a highly individualized, symptom-directed approach [1][2]. Because this condition affects multiple organ systems, the current standard of care involves a multidisciplinary team where specialists work together to address your specific symptoms [3][4].

The Core Strategy: Pacing for PEM

If you experience Post-Exertional Malaise (PEM) — the “crash” that happens after activity — the most important management tool is pacing [5]. Pacing is a strategy to help you stay within your “energy envelope” and avoid the “push-crash” cycle that can worsen your condition over time [5][6].

  • Stop, Rest, Pace: This involves breaking activities into small chunks and resting before you feel tired [5].
  • During a Crash: If you experience a crash, rest actively. Reduce cognitive and sensory input (dim lights, quiet room). Do not try to exercise or “walk it off.”
  • Activity Titration: A fixed, incremental exercise program (like Graded Exercise Therapy) can be harmful if you have PEM [5]. Instead, activity should be adjusted based on your current tolerance and how you feel 24 to 48 hours later, under clinician guidance [5][7].

Managing Autonomic Dysfunction and POTS

Many Long COVID patients develop Postural Tachycardia Syndrome (POTS) or other forms of dysautonomia, where the nervous system struggles to regulate heart rate and blood pressure [8][9]. Management typically starts with lifestyle changes before moving to medication, and requires careful safety screening:

  1. Hydration and Salt: Increasing fluid and salt intake can help expand blood volume and reduce dizziness, but this must be done under individualized clinician supervision. It can be unsafe if you have kidney disease, heart failure, or high blood pressure [9][10].
  2. Compression Garments: Waist-high compression stockings or abdominal binders can prevent blood from “pooling” in your legs [9][10].
  3. Medications: Doctors may prescribe medications like beta-blockers, ivabradine, midodrine, or fludrocortisone. These require careful monitoring as they can cause low heart rate, worsening fatigue, supine hypertension (high blood pressure while lying down), or electrolyte imbalances [10][9][11].

Investigational and Off-Label Treatments

Because there is currently no FDA-approved “cure” for Long COVID, many patients and doctors explore off-label treatments. While some of these show promise in early studies, they lack large-scale, high-certainty evidence and carry real risks. You should not self-start these therapies [12].

  • Low-Dose Naltrexone (LDN): LDN is being studied for its potential to reduce brain inflammation and fatigue [13]. However, it can precipitate opioid withdrawal, block opioid pain relief, and complicate emergency analgesia. Prescriber review and liver-safety screening are essential [14][15].
  • Metformin: This medication is being researched, but current evidence primarily supports its potential to prevent Long COVID if taken during the initial acute infection, rather than to treat established PASC [16][12].
  • Anticoagulants (“Triple Therapy”): Based on the theory that “microclots” block blood flow, some researchers have trialed blood thinners [17]. Empiric use solely for Long COVID is not routine care and carries severe risks of internal bleeding. It should only be used for another established medical indication or within an appropriately supervised research protocol [18][19].
  • Antihistamines: Some patients experience allergic-type symptoms, and some report relief with H1 and H2 blockers. However, this is not a routine treatment for all patients [20][12][16].

Always review treatments with a clinician to screen for safety, check interactions, and establish a plan for judging benefit and stopping safely [2][21].

Common questions in this guide

How should I pace activity if I have Long COVID and PEM?
If you have PEM, pacing is usually safer than pushing through fatigue. Break activities into small parts, rest before you feel exhausted, and adjust activity based on how you feel over the next 24 to 48 hours; a fixed graded exercise program may worsen PEM.
What should I do during a Long COVID crash?
During a crash, reduce physical activity and cognitive or sensory stimulation, such as bright light and noise, and rest actively. Do not try to exercise or walk it off; ask your clinician how to report a significant or worsening crash.
Can increasing salt and fluids help Long COVID-related POTS?
Extra fluids and salt may reduce dizziness in POTS by helping expand blood volume, but they are not safe for everyone. A clinician should check for kidney disease, heart failure, or high blood pressure and give individualized instructions before you increase them.
Can compression garments help with Long COVID-related dysautonomia?
Waist-high compression stockings or an abdominal binder may reduce blood pooling in the legs and ease some POTS symptoms. Ask a clinician which option is appropriate and how to use it safely as part of your overall treatment plan.
What risks should I know about POTS medications such as beta-blockers or ivabradine?
Doctors may use beta-blockers, ivabradine, midodrine, or fludrocortisone for selected POTS patients, but these medicines require monitoring. Possible problems include a low heart rate, worsening fatigue, high blood pressure while lying down, and electrolyte imbalances.
Is low-dose naltrexone an established treatment for Long COVID?
Low-dose naltrexone is being studied for Long COVID fatigue and inflammation, but it is not an established cure or routine treatment and should not be self-started. It can trigger opioid withdrawal, block opioid pain relief, and complicate emergency pain treatment, so prescriber review and liver-safety screening are important.
Should I take metformin or blood thinners for established Long COVID?
Current evidence for metformin mainly relates to possible prevention when it is taken during the initial infection, not treatment of established PASC. Blood thinners used only for Long COVID are not routine care and can cause serious internal bleeding; they should be used only for another medical indication or in appropriately supervised research.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Do I have Post-Exertional Malaise (PEM), and if so, how should we adjust any physical therapy to avoid the 'push-crash' cycle?
  2. 2.Is it safe for me to increase my salt and fluid intake, or do I have underlying conditions like high blood pressure or kidney issues that make this risky?
  3. 3.Are my heart rate and blood pressure responses consistent with POTS, and what are the contraindications for beta-blockers or ivabradine?
  4. 4.What is your view on the current evidence and safety limits for off-label treatments like low-dose naltrexone (LDN) for my specific symptoms?
  5. 5.If we decide to try a medication, how will we monitor for side effects and determine if it is actually working?
  6. 6.If I experience a significant crash or worsening of symptoms, what is the best way to communicate with your office for urgent guidance?

Questions For You

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References

References (21)
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    Long COVID-19 and primary care: Challenges, management and recommendations.

    Ahmed S, Ahmad E, Ahmad B, et al.

    Semergen 2024; (50(3)):102188 doi:10.1016/j.semerg.2023.102188.

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    Long COVID or Post-Acute Sequelae of SARS-CoV-2 Infection (PASC) and the Urgent Need to Identify Diagnostic Biomarkers and Risk Factors.

    Parums DV

    Medical science monitor : international medical journal of experimental and clinical research 2024; (30()):e946512 doi:10.12659/MSM.946512.

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    Multidisciplinary Center Care for Long COVID Syndrome-A Retrospective Cohort Study.

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This page explains Long COVID symptom management and treatment safety for educational purposes and is not medical advice. Work with a clinician before changing your activity, fluid or salt intake, or medications, especially if you have PEM or POTS.

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