# What I did to reduce the risk of Long COVID (and manage symptoms) after getting COVID

I recently got COVID for the first time, and I thought it might be of interest for me to share the measures I took to reduce my risk of getting Long COVID. 

I have no scientific or medical training, and this is not medical advice to you -- consider it a starting point for your own research and sense-checking.

I'd welcome input on any or all of it, especially guidance on how to approach a return to pre-COVID levels of physical activity. (If you want to discuss the risk of long COVID, though, better to do that on a post dedicated to that topic -- the most recent one seems to be [this](https://www.lesswrong.com/posts/GzjKoos4kgDcpcETB/any-significant-updates-on-long-covid-risk-analysis).)

*Update 3/27/22:* Since this post is centered around the approach I took -- citing sources but not attempting to make a robustly defensible general recommendation -- I feel the need to mention the following: after testing negative on antigen tests from 3/10 - 3/22, I somehow started testing positive again on 3/26. I suspect it is a later than usual rebound rather than a reinfection, but don't know. 

My symptoms are milder than they were originally, and I think all the measures I took still make as much sense as they did otherwise (I have no reason to think they increased the risk of rebound, and I would rather deal with the inconvenience of rebound than the risk of long COVID).

*Update 3/29/22*: Explicitly updated to include a section on things I did to manage symptoms, mainly to highlight the surprising efficacy of steam inhalation with mint oils for decongestion. 

Why care about long COVID?
==========================

My current assessment is that meaningful long-term impairment from COVID is not very common (otherwise I'd be hearing a lot more about it anecdotally), but nor is it trivially unlikely - a [Jan 2023 *Nature Reviews Microbiology*](https://www.nature.com/articles/s41579-022-00846-2) article cities two 2022 studies (covering about 40,000 patients in total) to estimate the incidence at 10-12% of vaccinated cases, whereas a [Dec 2022 post by Your Local Epidemiologist](https://yourlocalepidemiologist.substack.com/p/long-covid-an-update-and-gauging) looked at a few larger studies and came out with a 3% estimate--potentially an underestimate, based on discussion in comments [^dqlgp4vcpef]. I haven't tried to reconcile any of those studies to see where they shake out, but the point is the incidence seems non-trivial.

Anecdotally, a friend of mine who is one of the healthiest people I know (doesn't drink, exercises regularly, spent an extended period of time wearing a continuous glucose monitor and optimizing his diet accordingly, despite being nowhere close to prediabetic, etc.) recently shared that he is experiencing moderately troublesome long COVID despite a similarly mild case initially, so that makes the prospect more vivid in my mind.

Measures I took after getting COVID
===================================

Some context:

*   I'm a fairly healthy guy (normal BMI, exercise a bit ~5-6x a week, mild to maybe moderate asthma) in my mid-30s
*   I had a pretty mild case of acute COVID -- I had significant fatigue (I slept ~10-12 hours a day compared to my usual 7h during the workweek and 9h on weekends), very mild body ache for the first day or two, and minor congestion / cough until I started testing negative. So while many of the measures I took are also helpful for managing the severity during the acute phase of COVID, my main goal was to minimize my risk of long COVID
*   I have no medical or scientific background, and probably average or below-average numeracy/epistemics compared to the average LessWrong reader, though I have reasonably strong attention to detail and logical reasoning skills generally. I did not attempt to closely read or independently analyze the validity of any of the studies cited as sources below.

To reduce the risk of long COVID
--------------------------------

**Paxlovid**

*   *What:* As soon as I tested positive, I messaged my primary care practice and asked for Paxlovid to reduce long COVID risk. I claimed moderate-severity asthma as a qualifying factor even though my asthma is arguably more on the mild side than moderate). They (One Medical, in my case) readily agreed to prescribe.
*   *Why:* a [large study](https://www.medrxiv.org/content/10.1101/2022.11.03.22281783v1) found that Paxlovid reduced incidence of long COVID by 26%, regardless of vaccination status and history of prior infection
    *   The study was in older / higher-risk populations, but there is reason to believe that it would help with younger / lower-risk populations as well ([YLE actually thinks](https://yourlocalepidemiologist.substack.com/p/catch-up-quick-long-covid) it would have *greater* effect for younger people for reasons she doesn't explain)
    *   Possible downsides:
        *   It did leave a metallic taste in my mouth (even after I rinsed), but no worse than eating a bitter grapefruit, and rinsing / drinking water / eating things eliminated the taste for at least 5-10 min each time.
        *   Things that didn't bother me:
            *   From Googling and talking to my primary care, I found no significant risk of side effects (or contraindications with my other meds). Note that it does have [several drug interactions](https://erictopol.substack.com/p/paxlovid-and-long-covid#:~:text=There%20are%20many,course%20is%20completed.), so you make sure whoever is prescribing it to you is fully aware of all the medications and supplements you are taking)
            *   There's been talk of "Paxlovid rebound", but the [FDA recently found](https://abcnews.go.com/Health/clear-association-paxlovid-covid-19-rebound-fda/story?id=97887039) that people rebound at a comparable rate without Paxlovid. (Another source I read recently, analyzing other studies which had found a rebound rate on the order of 5-10% (if I recall correctly), speculated the earlier findings may be because people were tracking rebound more closely with Paxlovid.) In any case, I recall reading  (I believe from Eric Topol) that most rebounds are less less severe than the initial case.
    *   How to get it:
        *   If your PCP won't prescribe it for reasons you disagree with[^6lt0j81mhp], or you can't get ahold of them in time:
            *   For folks based in CA, a friend who just got COVID suggested calling the statewide COVID-19 hotline at 833-422-4255. Ask for treatment options and ask for a tele-health appointment. She was able to get a prescription in less than 30 minutes after calling, vs. her primary care which was going to take much longer.
            *   Otherwise, someone I'm forgetting posted about a year ago that Plushcare also is a good source for getting a prescription.

**Metformin**

*   *What:* I asked my PCP to prescribe me metformin to reduce long COVID risk. He agreed to prescribe it so I could replicate the (2-week) regimen in a recent RCT.
*   *Why:* [a large RCT found](https://yourlocalepidemiologist.substack.com/p/catch-up-quick-long-covid) that metformin reduced long COVID risk by 42% vs. placebo, 63% if taken within 4 days of symptoms. 
    *   Possible downsides:
        *   It can cause nausea or diarrhea; I seem to have avoided this by taking it with meals, but I do think it has caused a degree of indigestion
        *   It does have drug interactions
        *   If you drink too much alcohol while on it, it can lead to hypoglycemia, which is bad for you / dangerous. My PCP advised me to completely abstain from alcohol while I'm on it, which I'm fine with.

**Rest**

*   *Sleep:* I got as much sleep as I felt I needed to feel reasonably ok. If I was tired during the day, I napped instead of drinking more caffeine to power through.
    *   I've still been getting 9h of sleep a night even after I started testing negative, because I need it in order to feel reasonably good. I plan to do so until that changes, as I've read a lot to suggest that it's important to rest after the acute phase.
*   *Mental rest:* I didn't try to push myself to do work or be productive, although I did join a few meetings and join a few emails here and there.
*   *Physical activity:* I took a few very short, slow walks during the acute phase, but listened to my body and stopped when I was tired. (The primary care doc who prescribed my Paxlovid said a gentle walk was ok during the acute phase if I felt up to it, but that I should avoid walking more than a mile, and cautioned that exercise is generally a stressor and rest is important).
    *   Even now that I am testing negative, I'm holding off on anything beyond a gentle walk until my lingering symptoms (at this point, just tiredness) are completely gone, at the [advice of a researcher leading a major research project on long COVID](https://www.renews.co.nz/rushing-back-to-exercise-can-cause-long-covid/).
        *   ***I'd particularly welcome any further insight on this, as there isn't much written on it and I'd really like to get back to higher tempo partner dancing again in particular!***
*   *Cold showers:* I typically end a ~5 min hot shower with ~60 sec of ice cold water in the mornings because it makes me feel energized and peaceful. I haven't found anything written on this either way, but it intuitively feels like it's somewhat stressful on my body, so I'm holding off until all lingering symptoms are gone.

**Supplements**

A friend shared a [detailed COVID guide by Chris Masterjohn](https://chris-masterjohn-phd.myshopify.com/products/the-food-and-supplement-guide-for-the-coronavirus) (updated Aug 2022). He has a PhD in nutritional science and the guide is rather detailed, with references to studies for all its claims. From glancing at the studies many of them seemed to be small / not very robust studies. 

I bounced these off the primary care practitioner who prescribed me the Paxlovid; for the ones where she expressed concern or doubts, I Googled side effects and interactions and the generally recommended daily upper limit, and took them anyway (none of her concerns seemed especially grave). 

His guide goes into more detail on the specific types / brands of these to get in certain instances; if you do plan to proceed with this it's worth the $10 to buy it. Not all of these will be available within a day on Amazon / from local pharmacies, so if you're serious about this, stock up in advance.

Here are his recommendations I followed: 

*IMPORTANT:* I seem to recall there may be some instances where the safe upper limit varies between men and women. Please double check that for yourself if you're a woman. Also check if any of these have interactions with anything you're taking.

*   Zinc acetate: suck on 30-50 mg lozenge every 2h
*   Copper: 4-8 mg/day
*   Vitamin D3: I just stuck with my usual dose of 2500 IU daily.
    *   Masterjohn recommends 100,000 IU the first 2 days and 10,000 on subsequent days. A friend of a friend got similar guidance from an MD looking into supplements for COVID. 
    *   However,  the Andrew Weil Center for Integrative Medicine at University of Arizona cites concerns about inflammatory response during COVID with Vitamin D as a dietary supplement, so suggests caution with Vitamin D (see [here](https://drive.google.com/file/d/15n-90qAHDZ1nhWBJd0hbVjgLbNbkuMDm/view)). Coupled with my primary care doc's concerns that it is fat soluble and can be toxic at a certain level, and internet guidance that 4,000 IU is considered the safe upper limit (per [Harvard Health](https://www.health.harvard.edu/staying-healthy/taking-too-much-vitamin-d-can-cloud-its-benefits-and-create-health-risks#:~:text=Unless%20your%20doctor%20recommends%20it,considered%20the%20safe%20upper%20limit.) and [HealthLine](https://www.healthline.com/nutrition/vitamin-a#:~:text=Therefore%2C%20while%20it's%20crucial%20to,amount%20of%20this%20essential%20nutrient.)), I decided not to follow the Masterjohn recommendation here.
*   Vitamin C: 500 mg daily
    *   Masterjohn recommended 2 x 200 mg daily, but my primary care doc recommended 500-1000 mg, and this is well below the safe upper limit of 2000 mg [per WebMD](https://www.webmd.com/diet/features/the-benefits-of-vitamin-c).
*   Vitamin K2: 200 mcg daily.
    *   Followed Masterjohn's recommendation here. 
    *   Primary care doc raised concerns because she knew of no specific evidence to support this and had concerns about nausea, diarrhea, cramping, and kidney issues, but she said she didn't know what a problematic threshold was, and Googling suggested there is no known upper limit (e.g. [Metropolitan Dental Care](https://www.metropolitandentalcarenyc.com/blog/vitamin-k2#:~:text=Vitamin%20K2%20dosage%20should%20be,but%20can%20be%20exceeded%20safely.), [Futureyouhealth](https://futureyouhealth.com/knowledge-centre/vitamin-k2-benefits#:~:text=Adults%20should%20ensure%20they%20are,taking%20too%20much%20vitamin%20K2.)), so I ignored her.
*   Melatonin: 10mg daily
*   Black seed oil: 500 mg 2x daily
*   Listerine rinse and gargle 30 sec 2x daily
*   Betadine Cold Defense: 2 sprays in each nostril daily
    *   The primary care doc raised the concern that "overdoing this could increase risk of bacterial infections"; a quick Google yielded no evidence this would happen with a week's use, so I proceeded.
    *   Masterjohn favors povidone-iodine, but that seems to have issues in excess, so I went with his alternative of Betadine instead. 
    *   I skipped his recommendation of eye wipes because the mechanism of action there did not seem intuitively all that strong to me vs just...washing my face / showering a couple times a day.
    *   Note: Julia Wise recently did a deep dive on [Nose / throat treatments for respiratory infections](https://www.lesswrong.com/posts/cA24NRxMDDdWxPJuR/nose-throat-treatments-for-respiratory-infections) where she instead decided to do the following. Her post went up after my acute phase was over, so I have no POV on her conclusions vs Masterjohn's.
        *   – a spray with carrageenan or HPMC occasionally to reduce chances of catching covid at high-risk events  
            – carrageenan spray during the early part of a cold  
            – nasal washing and gargling with iodine during covid. Nasal washing seems like more of a hassle then a spray, but probably works better.
    *   IMPORTANT:  Julia's post cites studies indicating that iodine spray (of which Betadine is one brand) can make you test negative "at least temporarily," and says, "Some people do test negative after applying the iodine, but this doesn’t seem that relevant to whether you get better sooner." This makes me wonder whether the spray could temporarily suppress the virus but leave you still infectious a few hours later. As such, I'm going to avoid using it for a day (arbitrary period) before I start testing myself to see if I'm ready to exit isolation. I do seem to recall that Roche Pilot rapid antigen tests caution to avoid testing for at least half an hour after using any nasal spray, whereas Flowflex tests have no such guidance and in fact indicate no interactions with iodine. I don't know what to make of this.

Masterjohn recommendations I did not follow:

*   Vitamin A: he recommends 10,000 IU daily, but that seems premised on his recommended dose of Vitamin D, which I didn't follow. The recommended upper limit is 10,000, and the primary care doc raised vague concerns about risk of overuse, so I skipped this one.
*   Vitamin E: he recommends 20 IU of vitamin E, primary care doc raised similar concerns as with K2, and though 20 IU is well under what the [NIH](https://ods.od.nih.gov/factsheets/VitaminE-Consumer/#:~:text=Because%20of%20this%20risk%2C%20the,lower%20than%20those%20for%20adults.) says is the upper limit, for whatever reason I decided to skip this one.

Another recommendation I did follow:

*   PharmEPA: 1-2g 2x daily, taken with your fattiest meals
    *   This is from [LongCovidPharmD](https://pharmd.substack.com/p/i-have-covid-what-should-my-kids), who I was pointed to by a friend who has no specific scientific training but has been following COVID research carefully with a high degree of caution, and was pointed to her in turn by a COVID safety Facebook group with many scientists in it. The author describes herself as a “Doctor of Pharmacy currently doing independent & informal research with a special interest in Long Covid, ME/CFS, & other post-viral conditions.” From skimming her posts they appear quite thorough, scientifically conversant, and nuanced.
    *   I chose PharmEPA among the many other brands in her (frustratingly non-opinionated) table because in [another deep-dive article](https://pharmd.substack.com/p/high-dose-epa-for-long-covid-and#:~:text=WRAPPING%20UP%3A%20EPA%20in%20Long%20COVID%20and%20ME/CFS) she listed this as "one of the better options" and it was reasonably priced and available quickly on Amazon.
    *   I Googled briefly and found no significant risk of side effects or interactions.
    *   I ignored her other recommendations of Lactoferrin (because it seemed inconvenient to mix up) and EGCG (which seems to interact with Paxlovid)

**PCR test**

I remember reading quite some time ago that if you need disability leave / insurance assistance due to long COVID, it is helpful to have a PCR test as documentation that you actually had COVID. 

I am not sure whether this is still true or was ever true, but there was a free walk-in site less than a 20-min walk from my home in San Francisco, so I strolled over one day and got a test.

To manage symptoms / acute risks
--------------------------------

**Pulse Oximeter**

I monitored with a pulse oximeter that I bought on Amazon, 1-2x a day. After my rebound, I turned to using my Fitbit for this purpose. From a quick read of [this thread](https://community.fitbit.com/t5/Other-Versa-Smartwatches/Accuracy-of-SPO2-readings/td-p/4516053) it looks like it is less accurate but tends to report numbers lower than a medical-grade pulse oximeter, which works for my purposes.

This was more to reduce the risk of my acute case taking an unexpected turn for the worse than to reduce risk of long COVID. The primary care doc cautioned that people have been reported to have dangerously low oxygen levels before they feel distress subjectively. She advised that if my readings reach the low 90s, I should reach out, and if they drop to the 80s I should go to the emergency room immediately.

**Robitussin DM**

My parents (including my mother, who's lived her whole life with asthma more severe than I have currently) raised concerns about the congestion "settling into my lungs" even though it was not particularly bothering me, so I took Robitussin 1-2x a day till my congestion was gone. My cough did occasionally reach a level where it would interrupt my sleep, so the DM part of the medication was helpful for that.

**Steaming with mint oil drops**

I boiled water, poured it into a large bowl, added a few drops of Olbas herbal drops (contains peppermint and other oils), plopped a towel over my head to keep in the steam, lowered my head into the bowl, and inhaled deeply until the water had cooled to the point where it was no longer emitting vapors. This was shockingly effective in alleviating my congestion (which reached an unpleasant level during my second bout of COVID) -- my congestion was pretty unpleasant before I did this, and just minorly bothersome the day after. (Quite possible this was partly due to a natural trend that would have happened anyway, but, um, you can tell immediately when this method loosens up congestion.)

I imagine the specific brand doesn't matter and any similar drops would be fine.

Note: the label suggests 20 drops, which (in about 2 cereal bowls' worth of water) was *intense*. Maybe start with 2-3 drops and add more after inhaling.

**Gargling **

I gargled with warm, very salty (more salty than the ocean) water several times a day, as needed to alleviate sore throat and chest congestion, and preventatively before bed for the same purpose.

**Drinking hot water**

Also to alleviate chest congestion.

[^dqlgp4vcpef]: There's some back and forth in the comments which suggests the study she used may be underestimating...would welcome thoughts on that. Regardless, she thinks it's a large enough concern to continue tracking, though from her description of her and her family's current approach to COVID in another post, not large enough to avoid indoor dining or take other significantly restrictive measures. 

[^6lt0j81mhp]: I have read in several places that Paxlovid is underprescribed; I'm not sure why. When my parents got COVID last fall, they asked a bunch of friends who are MDs and their consensus was that there isn't much of an evidence base yet (the study showing impact on long COVID risk was still in preprint, though no one raised that point specifically) and it wasn't necessary in low-severity cases. To me, the prospect of long COVID far outweighs any theoretical generic precaution about side effects (despite reading up on Paxlovid a fair amount, I haven't seen anything even speculating that it has significant risks), so I find this odd.