One single guideline instead of thirty guidelines and documents

At the start of the pandemic, doctors produced a range of guidelines and other documents for lingering symptoms following a COVID-19 infection. That all had to happen quickly and little knowledge from research was available at the time. The recommendations did not always align well with each other.

As GPs did not yet have sufficient experience and knowledge with the symptoms, they often referred patients to different hospital specialists and many additional tests were performed. Therefore, we have now produced a single multidisciplinary guideline with unequivocal recommendations for treatment in primary and secondary care. From this, we have produced a Dutch College of General Practitioners Standard (NHG Standard) specifically for GPs. This contains a clear description of all evidence according to best practices.

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Therefore, we have now produced a single multidisciplinary guideline with unequivocal recommendations for treatment in primary and secondary care. From this, we have produced a Dutch College of General Practitioners Standard (NHG Standard) specifically for GPs.
Jacintha van Balen
General practitioner, scientific employee of the Dutch College of General Practitioners Standard

The associated symptoms are typical for the aftermath of a COVID-19 infection

The guideline states which symptoms fit the aftermath of COVID-19, such as tiredness, shortness of breath, cognitive symptoms ('brain fog') disruptions to smell and taste, anxiety and sleeping problems. The symptoms are typically difficult to distinguish from each other. They are related symptoms and they are intertwined.

Additional investigations are not usually worthwhile

The guideline also states when you need to perform diagnostics and which diagnostics these are. Additional investigations such as lung photos, ECGs an MRI scans of the brain and D-dimer determinations in primary care are not useful. In secondary care, respiratory gas analysis is sometimes performed. With that, you can determine whether the symptoms originate from the heart, lungs or the musculoskeletal system. And, of course, you do additional investigations if you suspect that somebody does suffer from a long embolism, heart infarct or cardiovascular disease.

The guideline prevents conflicting recommendations

The guideline also describes the treatment. In primary care, this consists of lifestyle recommendations and information, physiotherapy and occupational therapy, dietary advice and speech therapy for people with voice problems. Sometimes, several paramedical therapists are involved in the treatment of the patient. The guideline states that they must coordinate the treatment with each other to prevent conflicting recommendations. One such example is the physiotherapist starting to build up activities again (exertion tolerance) while the occupational therapist advises the patient to take things easily (energy management).

Refer to a multidisciplinary diagnostic consultation

If, after six months, patients have still not recovered enough from moderate to severe related symptoms despite the treatment, or if the complex of systems does not match COVID-19, the GP should refer the patient to secondary care, preferably to a multidisciplinary diagnostic consultation. The multidisciplinary team jointly examines the symptoms and differentiates these. Via this consultation, patients are referred to the pulmonologist, cardiologist or rehabilitation physician, for example.

The guideline is properly aligned with everyday practice

The guideline has been in use since March 2022. It has been well received and clearly meets the needs in practice. Primary and secondary care providers know how to use the guideline. Based on the evidence, we have been very reticent in issuing recommendations to prescribe drugs. For example, in the guideline, we do not recommend prescribing corticosteroids, inhalation medication or painkillers. They have proven not to be effective. This guideline replaces all of the various preceding documents. Instead of thirty different guidelines and documents, we now have one single guideline.

Long-term symptoms following a COVID-19 infection have been brought to the attention of all care professionals

The guideline is also useful for properly bringing the long-term symptoms following a COVID-19 infection to the attention of all care professionals so that they can deal with the symptoms better. The symptoms are highly debilitating for patients who previously often enjoyed good health. Now they remain patients long after the infection has been cured. Of course, that has very far-reaching effects and these should definitely not be played down.

Proud that we succeeded

Producing the guideline was a complex process. It involved forty different parties and that is an awful lot. For example, patient representatives from the Lung Foundation Netherlands provided input during the entire process. The Dutch College of General Practitioners and the Knowledge Institute of the Dutch Association of Medical Specialists had to align their working methods with each other to produce the guideline. The project was realised under considerable time pressure; we had just 15 months to complete it. For a non-complex NHG Standard guideline, we usually allow 18 months. A lot of coordination was needed between the various parties. We are proud that we succeeded within the time allotted to us.

Relevant publications

Author: Riëtte Duynstee
Photo: private collection  Jacintha van Balen