First Canadian guidelines now available for post-COVID-19 condition (PCC)

A group from McMaster University in Hamilton, Ontario has spearheaded the development of the first Canadian evidence-based guidelines for diagnosing, managing, preventing and treating post COVID-19 condition (PCC), also known as “long COVID,” “long-haul COVID” or “chronic COVID.” The guidelines are designed to educate patients, healthcare professionals and policymakers about this relatively new condition, which is estimated to affect more than one million Canadians.1PCC usually appears within three months after an acute COVID-19 infection and lasts at least two months. It can develop in people who have experienced any severity of acute COVID-19 infection, from mild to severe, and can even occur in people who were initially asymptomatic. Common symptoms of PCC include pain, fatigue, shortness of breath, sleep problems, brain fog and post-exertional malaise. Symptoms can be persistent or episodic, and can change or worsen over time. PCC has significant negative effects on daily life.2The new Canadian guidelines were developed by the CAN-PCC Collaborative, which was comprised of a multidisciplinary team of more than 150 healthcare professionals, policymakers, international experts and people with lived PCC experience. Funding for guideline development was provided by the Public Health Agency of Canada.1 The guidelines include about 100 recommendations (available in English and French), with the strength of each recommendation specified. Most of the recommendations are based on low certainty evidence. The recommendations are searchable using key words and are also available in a “plain language” summary format. Several “good practice statements” that cover various topics related to post COVID-19 condition are also included. Recommendations and good practice statements can be viewed at here.1-3Using the “map view,” recommendations are categorized into six main topics:PreventionTesting, identification and diagnosisClinical interventionsNeurological and psychiatric topicsPediatric and adolescent topicsHealthcare services and systems, social support.Highlights of recommendations for prevention or treatment of post COVID-19 condition:A short (10–14 day) course of metformin is suggested in adults with acute COVID-19 infection to prevent post COVID-19 condition (conditional recommendation, low certainty in the evidence). Studies used a range of doses and durations (10–14 days) of metformin. Gastrointestinal adverse effects may be reduced by starting at a lower dosage (e.g., 250 mg po bid).Nirmatrelvir/ritonavir (Paxlovid) is suggested in adults with acute COVID-19 infection to prevent post COVID-19 condition (conditional recommendation, very low certainty in the evidence). Studies used five days of nirmatrelvir 300 mg/ ritonavir 100 mg, with reduced renal dosing (nirmatrelvir 150 mg/ritonavir 100 mg) for people with chronic kidney disease (eGFR 30–60 mL/minute); nirmatrelvir/ritonavir is not recommended if the eGFR is < 30 mL/minute. A discussion of the side effects and contraindications of nirmatrelvir/ritonavir should be included in shared decision-making with patients. Tools such as the COVID-19 Drug Interactions Checker should be used to assess and manage interactions.Metformin is suggested in adults with post COVID-19 condition who have a new COVID-19 infection (conditional recommendation; very low certainty in the evidence). The two largest randomized controlled trials in nonhospitalized adults with acute COVID-19 used metformin 750 mg twice daily for 10 days (one study) or a gradually increasing dose (day 1: 500 mg, day 2–5: 500 mg twice daily, day 6–14: 500 mg in the morning and 1000 mg in the evening) (second study).In adults with confirmed post COVID-19 condition who have a new acute COVID-19 infection, the use of nirmatrelvir/ritonavir is suggested compared to not using nirmatrelvir/ritonavir (conditional recommendation; very low certainty in the evidence). The recommended dosage is nirmatrelvir 300 mg and ritonavir 100 mg (Paxlovid) twice daily for five days.Metformin or nirmatrelvir/ritonavir is suggested for adults with post COVID-19 condition and a new COVID-19 infection (conditional recommendation; very low certainty in the evidence). Each drug has an individual conditional recommendation favouring its use, over no treatment. Evidence was insufficient to formulate a recommendation on the concurrent use of both drugs.Remdesivir is suggested compared to not using remdesivir in adults with confirmed post COVID-19 condition who have a new acute COVID-19 infection (conditional recommendation; very low certainty in the evidence). The use of remdesivir is most feasible and likely to benefit hospitalized adults and/or those with more severe illness who do not have indications for other COVID-19 therapies. Randomized controlled trials administered remdesivir intravenously, 200 mg on day 1, followed by 100 mg daily for an additional four or nine days.Rest/pacing is suggested for adults with confirmed post COVID-19 condition and post-exertional malaise or post-exertional symptom exacerbation (conditional recommendation; very low certainty in the evidence).Activity, movement or exercise-based interventions are suggested for adults with confirmed post COVID-19 condition who do not experience postexertional malaise/postexertional symptom exacerbation (conditional recommendation, very low certainty of evidence).In adults with post COVID-19 condition and co-existing cardiac dysautonomia (postural orthostatic tachycardia syndrome, inappropriate sinus tachycardia), ivabradine, beta-blockers, pyridostigmine or midodrine are suggested, as appropriate (conditional recommendation; low certainty in the evidence). Evidence was available for monotherapy only, not combination therapy. Doses and frequency of administration: ivabradine 2.5–10 mg twice daily; carvedilol 3.125–12.5 mg twice daily, metoprolol 25–350 mg per day; pyridostigmine 30 mg or 60 mg per day; midodrine 10 mg per day. It is important for healthcare providers to identify the predominant sign/symptom of cardiac dysautonomia to help guide choice of therapy. These include: 1) tachycardia (ivabradine, beta-blockers), and 2) supine hypotension (midodrine, pyridostigmine).Antihistamines are suggested for adults with post COVID-19 condition and signs and symptoms compatible with mast cell activation syndrome (conditional recommendation; very low certainty in the evidence).Antihistamines are not suggested for adults with post COVID-19 condition without signs and symptoms compatible with mast cell activation syndrome, (conditional recommendation; very low certainty in the evidence).Nirmatrelvir/ritonavir use is not suggested for adults with confirmed post COVID-19 condition (conditional recommendation; very low certainty in the evidence).Intranasal, inhaled or oral corticosteroids are not suggested for adults with confirmed or suspected post COVID-19 condition (conditional recommendation; very low certainty in the evidence).Low-dose naltrexone is not suggested for people with post COVID-19 condition (conditional recommendation; very low certainty in the evidence). This recommendation will be re-evaluated in 2026 or earlier if higher certainty evidence for critical outcomes becomes available.Remdesivir is not suggested for adults with confirmed post COVID-19 condition (conditional recommendation; very low certainty in the evidence). A separate recommendation has been issued for adults with post COVID-19 condition with a new acute COVID-19 infection (see above).Taurine supplementation is not suggested for adults with confirmed or suspected post COVID-19 condition (conditional recommendation, very low certainty in the evidence).Antiplatelet therapies are not suggested in adults with post COVID-19 condition who do not have a pre-existing indication for antiplatelet treatment (e.g., myocardial infarction, stroke/transient ischemic attack) (conditional recommendation; very low certainty in the evidence). The guidelines also include various decision aids, resource sheets and infographics to help patients make informed decisions together with their healthcare providers. With ongoing financial support, the CAN-PCC Collaborative plans to update the recommendations as new evidence emerges, to ensure that healthcare providers and patients have access to the most current information about post COVID-19 condition.References:Ward A. McMaster leads creation of Canada’s first guidelines for post COVID-19 condition. March 21, 2025. (accessed March 27, 2025).CAN-PCC. CAN-PCC guidelines and good practice statements. (accessed March 27, 2025).CAN-PCC. Canadian guidelines for post-COVID-19 condition (CAN-PCC). CAN-PCC recommendations. (accessed March 27, 2025).

First Canadian guidelines now available for post-COVID-19 condition (PCC)

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