Both Long COVID and myalgic encephalitis/chronic fatigue syndrome (ME/CFS) are post-viral conditions with overlapping symptoms. At the International Association for Chronic Fatigue Syndrome/Myalgic Encephalitis 2022 Conference, Charles W. Lapp, M.D., medical director at North Carolina’s Hunter-Hopkins Center, and other experts discussed findings for five (5) treatment methods being studied for managing common post-viral symptoms* such as:

• Brain fog
• Chronic pain
• Extreme fatigue
• Post-exertional malaise
• Postural orthostatic tachycardia syndrome (POTS)

The majority of the methods are already approved for other conditions.

Pyridostigmine for exercise capacity

Pyridostigmine (brand names Mestinon and Regonol) has been shown to reduce POTS-related symptom burden and heart rate. At the conference, David M. Systrom, M.D. of Boston’s Brigham and Women’s Hospital presented study findings indicating that pyridostigmine improves exercise capacity and that neurovascular dysfunction is responsible for the patients’ exercise intolerance.

• 45 ME/CFS patients were randomized to receive either pyridostigmine or a placebo. 
• 50 minutes later, VO2 max, cardiac output, and right atrial pressure significantly improved with the drug, while decreasing in the placebo group.

“Pyridostigmine may be a useful repurposed off-label treatment [for] a subset of patients with exercise intolerance,” Systrom wrote. Added Lapp, “We’ve used Mestinon for years because it helps with POTS…Systrom is taking it to a new level.”

Oxaloacetate for fatigue

Oxaloacetate is a nutritional supplement that completes a step in the body’s natural energy production that is depleted in people with ME/CFS. David Lyons Kaufman, M.D. of California’s Center for Complex Diseases presented findings from a study of the drug’s ability to treat physical and mental fatigue.

• 76 long-time ME/CFS patients and 43 patients with Long COVID fatigue were given doses from 500 mg twice a day to 1,000 mg three times a day for six weeks.
• About 33% of ME/CFS patients and 47% of Long COVID patients experienced significant improvement, compared to roughly 6% of controls.
• The optimum dose was 1,000 mg taken twice daily, with one pill at breakfast and the second at lunch to avoid indigestion and insomnia.

Another study is now underway to confirm the results. The supplement currently costs about $49 for 30 250-mg capsules—roughly a 4-day’s supply at 2,000 mg per day. Said Lapp, “It’s a benign drug, and it’s over the counter. I would give it to any patient who’s got a big wallet. If they’ve got the money, they can order it tonight.”

Inspiritol for controlling immune response and reversing fatigue

Experimental drug Inspiritol is a nasal spray intended to treat symptoms of respiratory distress with antioxidant, anti-inflammatory, antiviral, and antibacterial properties using naturally occurring compounds. Liisa K. Selin, M.D., Ph.D. of the University of Massachusetts Chan Medical School said the approach is based on the premise that ME/CFS and Long COVID result from a dysregulated immune response. 

The drug, originally designed for chronic obstructive pulmonary disease (COPD) and asthma, acts to modulate immune response and has been effective against COVID-19.

• In initial research, four ME/CFS patients and five Long COVID patients treated with Inspiritol for 2-15 months reported symptom improvement, with cough the only side effect.

The medication is still in the investigational stage. 

Stellate ganglion block for Long COVID symptoms

The stellate ganglion is part of the sympathetic (“fight or flight”) nervous system, located in the neck on both sides of the voice box. A stellate ganglion block involves blocking pain-causing nerve impulses from reaching the head, neck, upper chest, and upper arm by injecting a local anesthetic near the ganglion. The practice has been used for decades for conditions like complex regional pain syndrome and was recently studied for Long COVID.

• Of 11 Long COVID patients, at least 5 experienced significant improvement regarding fatigue and post-exertional malaise, memory and concentration, rapid heartbeat, POTS, sleep, anxiety, and depression.
• Another study involving five MD/CFS patients also showed improvement.

While it’s generally safe and a common procedure at pain clinics, there’s a “high risk” of injuring a vital blood vessel or nerve in the neck and should only be performed with fluoroscopy or ultrasound, Lapp says. He doesn’t consider it a first-line treatment for ME/CFS or Long COVID.

Vagus nerve stimulation for autonomic symptoms

The vagus nerve is one of 10 cranial nerves and the longest in the autonomic nervous system (ANS), which controls automatic functions such as heart rate and blood pressure. In transcutaneous auricular vagus nerve stimulation (taVNS), the vagus nerve is stimulated by applying electrodes to the ear. 

Physiotherapist Nicola Clague-Baker, Ph.D.at the University of Liverpool, U.K., presented results from an international survey of 131 people with ME/CFS who had undergone taVNS.

• Over 30 improvements were reported, most commonly in post-exertional malaise (39%) and brain fog (37%).
• More than 20 side effects were also reported, such as headaches (15%) and long-term site irritation (9%). 
• 80% planned to continue taVNS, 67% said they’d recommend it to fellow patients, and 56% rated taVNS as moderately to very beneficial.  

Lapp said taVNS systems are sold online and he’s seen them work well for migraines. He urged caution due to the side effects, however. “It’s putting an electrical current through your brain. In my mind, it’s another last-ditch measure.”

*Tucker, M. E. (2022, August 5). Treatments Explored to Ease Post-Viral Symptoms of ME/CFS and Long COVID. Medscape Medical News. https://www.medscape.com/viewarticle/978707#vp_3

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