Resilience and recovery for COVID-19 long haulers

As the healthcare industry continues to face the novel coronavirus (COVID-19) pandemic head-on, there is much discussion around post-COVID-19 syndrome, also known as long haul syndrome. The 2021 Institute for Functional Medicine Annual International Conference hosted Leo Galland, MD, Sue Haddow, MD, Imran Khan, MD, and Marwa Hazzah, MD, for a panel discussion on building resilience and supporting recovery in so-called COVID-19 long haulers.

According to Galland, people who have asymptomatic infection with SARS-CoV-2, the virus that causes COVID-19, do not do not experience post-acute sequellae of COVID-19 (PASC). The causes of PASC are rooted in the pathophysiology of COVID-19, he said.

Physiologic abnormalities after acute COVID-19 resolution include:

• Abnormal arterial stiffness 4 weeks after in healthy young adults with mild disease
• Impaired flow mediated vasodilation at 3 months after hospital discharge in 50 percent
• Persistent activation of the innate and adaptive immune systems
• Gut dysbiosis with decreased bacterial diversity, increased fungal richness

These symptoms can be traced to a deficiency of angiotensin converting enzyme 2 (ACE-2), Galland said, the counter-regulatory arm of the renin angiotensin system. In COVID-19, ACE-2 is the principal cellular receptor for SARS-CoV-2, destroyed by viral cell entry. Neurovascular consequences of ACE-2 depletion results in impaired baroreceptor function, increased central nervous system (CNS) sympathetic discharge, and postural orthostatic tachycardia syndrome (POTS).

According to Galland, there are several gastrointestinal consequences of ACE-1 depletion, including impaired amino acid transport, serotonin deficiency, loss of beta-defensing, dysbiosis including decreased bacterial diversity, fungal overgrowth such as Candida albicans and auris, and Aspergillus flavus, and increased permeability, which has been linked to  cardiac dysfunction.

Galland offered a five-part strategy for PASC recovery, which is part of his COVID-19 protection protocol:

• Optimize lifestyle, recondition
• Enhance ACE2 activity
• Repair end-organ damage
• Alleviate sociocultural stress and post-traumatic stress disorder (PTSD)
• Search for and eliminate persistent infection, primary or secondary

Additionally, ACE-2 enhancement in PASC can be addressed with vitamin D, resveratrol, curcumin, omega-3 fatty acids via apelin signaling, and alpha-lipoic acid via TACE inhibition, as well as Astragalus membranaceous root and Scutellaria baicalensis, ecdysterones that activate the MAS receptor, a principal target for ACE-2 effects, he said.

Haddow presented her clinical experience treating patients with what she referred to as chronic COVID-19 syndrome. Haddow practices as Hennepin Healthcare, and integrated system of care serving downtown Minneapolis and surrounding communities. Nearly half of the patients she sees have no insurance.

Early on in the pandemic, Haddow said her integrative healthcare practice initiative an Immune Support Package for patients and staff, which provided support beyond the recommended practices of masking, handwashing, social distancing, and the like. The packages were created in collaboration with their on-site pharmacists, who helped choose safe doses and check for interactions with patients’ medications. The hope was to mitigate severity of illness, before the healthcare industry knew anything about “long COVID-19,” she said.

The immune support package cost $30 for 2-3 months’ supply. It contained:

• Vitamin A, 8,000 international units
• Vitamin C, 500 milligrams, BID
• Vitamin D3, 2,000 international units
• Melatonin, 5 milligrams, HS
• Curcumin 500 milligrams
• Zinc, 30 milligrams
• NAC, 600 milligrams

The packages also included recommendations for sleep, laughter, breathing, relaxation, and nutrition, along with a clear disclaimer that it does not treat or prevent or treat COVID-19, Haddow said.

Khan said the most common symptoms that can linger with post-COVID-19 syndrome include:

• Fatigue
• Difficulty breathing
• Joint pain
• Chest pain
• Brain fog, including an inability to concentrate and impaired memory
• Loss of taste and/or smell
• Sleep issues

Khan said treatment directions point to long-term cytokine signaling issues with post COVID-19 infection. Practitioners should test and treat patients early, and use the functional medicine matrix, including supplementing with vitamin C, vitamin D, and zinc.

Hazzah said focuses must include decreasing inflammation, boosting innate immunity, and restoring balance. Diet recommendations included low-glycemic load, high phytonutrient content, a low omega-6 to omega-3 fatty acid ration, and low saturated and trans fatty acids. Supplements included vitamin D, vitamin C, zinc, vitamin A, melatonin, omega-3 fatty acids, selenium, NAC/glutathione, probiotics, turmeric, ginger, quercetin, green tea, and echinacea.

Editor's note: This article is part of our live coverage of the 2021 Institute for Functional Medicine Annual International Conference. Click here for a list of full coverage.