What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?

Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...

From a rheumatology perspective, I would be mindful that there is accumulating data that like other viral infections, but perhaps even more so, COVID-19 can be a significant "epigenetic hit" to immunologic homeostasis, with the triggering of nascent autoimmune disease not uncommon. Profound fatigue ...

Note that there is a multi-center clinical trial (RECOVER trials) starting with this question in mind.

One protocol looks at exercise intolerance/fatigue. Another protocol trial looks at sleep disturbances (either hypersomnia or disrupted sleep).

Hypersomnia patients will be randomized to modafinil ...

• Vitamin D, if the level is below 35
• Vitamin C
• Attention to circadian rhythms (exposure to sunlight in the morning)
• Minimizing artificial light at night (blue light-blocking glasses)
• Minimize exposure to non-native EMF

Chronic fatigue in long COVID is so debilitating that as long as other diseases, nutritional deficits, or sleep disorders are not present, I would treat it with low-dose modafinil. While most medications have some potential side effects, modafinil is generally very well tolerated at low doses. I wou...

• Treat insomnia if present (Melatonin, etc.) and attention to sleep patterns.
• Consider supplementation with vitamin D, fish oil, magnesium, and CoQ10.
• Rule out myalgia, myopathic syndromes, EDS, and other collagen connective tissue disorders, spondylosis, Lyme, other tick-borne disorders, EBV, etc.
...

Assuming this is the case, I would add that making the distinction between chronic fatigue, exercise intolerance, and post-exertional malaise has helped me a lot in guiding diagnostics to then recommend treatments. For example, exercise intolerance will lead me to work with a cardiopulmonary exercis...

Very common, and very frustrating (for both patient and physician). Like others, we used to commonly prescribe modafinil, naltrexone, SSRI, or SSNIs, all with occasional dramatic success but far more commonly with minimal or no change in the patient’s underlying status.

In contrast to those who pres...

I’ve had good results with the metformin protocol for these patients. Helps with the brain fog, especially.