In the Fragmented Landscape of Long COVID Care, Pharmacists Are Essential

In the 5 years since the start of the COVID-19 pandemic, post-COVID-19 sequelae, also known as long COVID, has grown in notoriety and concern. Concurrently, the landscape of research, possible treatments, and patient support has become increasingly fractured. Experts at Infectious Disease Week 2025 stressed that, today, long COVID remains a complex, heterogeneous syndrome, with multidisciplinary cooperation a critical component of providing frontline support and addressing patient challenges.¹

The expert panel included moderators Zanthia Wiley, MD, associate professor of medicine at Emory University School of Medicine and Michael Peluso, MD, assistant professor at University of California San Francisco. Featured panelists were Marta Cerda, Juris Doctor, CEO of ASI Home Care; Melissa Stockwell, MD, MPH, department of pediatrics at Columbia University Irving Medical Center; and Igho Ofotokun, MD, MSc, FIDSA, Grady distinguished professor of medicine at Emory University School of Medicine.¹

What is the Lived Experience of Long COVID?

Across their presentations, the panelists focused on the lived experiences of patients with long COVID, while providing updates on possible therapeutics, research initiatives, and challenges in pediatric, adolescent, and adult long COVID management.¹

Setting the tone for the conversation, Cerda shared her personal journey with long COVID. Cerda said the constellation of symptoms associated with her long COVID presentation, including in the cardiovascular (heart palpitations), digestive (nausea), musculoskeletal (leg inflammation), respiratory (scarred lungs, shortness of breath), nervous (headache, brain fog, dizziness), and integumentary (rashes) systems.¹

Cerda urged the audience to imagine dealing with these symptoms; especially those that many in the public refuse to recognize as real.¹

“Imagine going to work knowing that your brain does not function the way it used to. Imagine people not believing that all of this is happening to you. Please do not let millions of us suffer with long COVID,” Cerda pleaded. “We do not want to lose hope for our future.”¹

What are Roadblocks in Pediatric and Adolescent Long COVID Research?

Numerous misconceptions about long COVID, particularly in pediatric and adolescent populations, have been disseminated since the condition first became a public health concern. Namely, many individuals simply do not believe that children can develop long COVID. In the beginning of her presentation, Stockwell sought to address this misconception head-on.¹

“We know that long COVID is a significant pediatric public health problem,” Stockwell explained. She cited information, although varying in predictions, estimating that likely 2% to 10% of infected children have long COVID symptoms, which could mean that 1.3 to 6.5 million children have long COVID. This would mean that more children have long COVID than those who have asthma, epilepsy, or a cancer diagnosis. In Stockwell’s view, “Long COVID is not rare.”^1,2

Stockwell outlined numerous unique challenges in understanding long COVID that have made it difficult to advance the field. Numerous difficulties have been reported in assessing symptoms in children, especially younger ones, namely due to inconsistent manifestations and the inability of younger children to describe symptoms. Regarding current research initiatives, many study designs lack comparison groups, and there is no standardized definition of childhood long COVID across studies.¹

Through the Researching COVID to Enhance Recovery (RECOVER) initiative, investigators like Stockwell seek to better prevent and treat long COVID in the future. In the observational RECOVER-Pediatrics initiative, Stockwell and her fellow authors have begun to characterize long COVID in children and adolescents while providing an overview of symptoms present during early childhood. They were able to develop an age-specific Long COVID research index to aid researchers in determining the likely presence of long COVID.^1,3,4

Still, Stockwell described the current dearth of specifically dedicated pediatric long COVID trials. Although the RECOVER initiative continues to investigate possible therapeutics, more research is desperately needed to elucidate methods for symptom relief and underlying mechanisms of long COVID.¹

"We need to protect children through research and not from research,” Stockwell concluded. “It's really important we continue our pediatric trials."¹

What Therapeutic Challenges Are There?

Moving to a discussion on available therapeutic options, Ofotokun noted that research and development faces major hurdles since long COVID is so poorly understood. Echoing concerns from Stockwell, the lack of a standard definition that encompasses all clinical manifestations of long COVID, along with a disease trajectory that varies widely from patient to patient, makes clinical trials difficult to interpret.¹

Numerous agents have been or are currently being evaluated as possible therapeutics for long COVID management. Ofotokun characterized these treatments into those acting as an antiviral, those acting as immune modulators, and those providing symptomatic relief.¹

Antivirals

Ofotokun provided a series of antiviral agents that have been tried for the treatment of long COVID. Chief among these is nirmatrelvir-ritonavir (Paxlovid; Pfizer) tablets, FDA-approved to treat mild to moderate COVID-19 in nonhospitalized patients at high risk for progression to severe COVID-19.^1,5

Numerous trials have evaluated nirmatrelvir-ritonavir in the setting of long COVID. Unfortunately, these studies have generally found that the drug combination is not meaningfully effective in long COVID care. Sawano et al published results in The Lancet Infectious Disease indicating that nirmatrelvir-ritonavir for 15 days not not significantly improve health outcomes in patients with long COVID compared with placebo-ritonavir at day 28. ^1,6

Another trial, published by Geng et al in JAMA Internal Medicine, came to a similar conclusion, finding that although the regimen was safe, there was not a significant benefit for improving select long COVID symptoms.^1,7

Immune Modulators

Low-dose naltrexone (Vivitrol; Alkermes, Inc), also cited as an intriguing agent for study by Stockwell, brings the potential to treat the chronic inflammation associated with long COVID. The agent, originally approved in 1984, is an opioid receptor antagonist used in opioid use disorder. Ofotokun said the drug’s anti-inflammatory properties could be leveraged to address the underlying mechanisms of long COVID.^1,8

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) could also serve as intriguing candidates for long COVID treatment. The weight loss medications, specifically tirzepatide (Monjouro, Zepbound; Eli Lilly and Company) in a microdose, could provide relief to the symptoms of long COVID without causing weight loss.¹

Symptomatic Relief

Ofotokun addressed a series of methods that could provide symptomatic relief to patients with long COVID. One pertinent method is a stellate ganglion block, involving the injection of a local anesthetic that targets the sympathetic trunk of the cervical system. This injection could lead to improved neurovascular, neurocardiac, and neuroinflammatory presentations in patients with long COVID.¹

What is the Role of Pharmacists?

Clearly, “there is a lot of work to be done to come to the state where we have an effective treatment for long COVID,” as Ofotokun said. In the meantime, pharmacists are critical players in ensuring that patients with long COVID are heard, their concerns are addressed, and their symptoms are managed as effectively as possible.¹

Stockwell agreed with this sentiment, noting that pharmacist involvement in long COVID management is “an excellent idea.” She said pharmacists can act as “first-line responders” by referring patients to experts and suggesting that parents have their children evaluated for long COVID. Pharmacists can “really try to get the message as much as possible to anybody that long COVID exists, that it can look different than in adults, and that you should talk to your pediatrician” to consider evaluation.¹

Agreeing with the sentiment, Ofotokun said patient validation is essential. He explained that patients can feel ignored by their providers and end up feeling like their symptoms are “in their head.” Pharmacists can ensure that patients’ experiences are validated, and that their biological abnormalities are recognized. Further, Ofotokun explained that, although research is ongoing for direct long COVID treatments, pharmacists can prescribe treatments for the symptoms that can be addressed.¹

Especially in clinics, pharmacists “are a really critical and often underappreciated member of the team,” Peluso said. Pharmacists can use their medication expertise to evaluate drug combinations or supplements that patients may be experimenting with, assessing whether they may be making their symptoms worse due to unexpected drug-drug interactions.¹

“Having a pharmacist on the team to really be on the lookout for those potential issues and help navigate them is really important,” Peluso explained.¹

REFERENCES

1. Wiley Z, Peluso M, Ofotokun I, Cerda M, Stockwell M. “Long COVID: Where Are We Now and What Can We Do?” Symposium. Presented: Infectious Disease Week 2025 Annual Meeting; October 20, 2025; Atlanta, Georgia. Accessed Online October 20, 2025.

2. Pellegrino R, Chiappini E, Licari A, Galli L, Marseglia GL. Prevalence and clinical presentation of long COVID in children: a systematic review. Eur J Pediatr. 2022;181(12):3995-4009. doi:10.1007/s00431-022-04600-x

3. Gross RS, Thaweethai T, Kleinman LC, et al. Characterizing long COVID in children and adolescents. JAMA. 2024;332(14):1174-1188. doi:10.1001/jama.2024.12747

4. Gross RS, Thaweethai T, Salisbury AL, et al. JAMA Pediatr. 2025;179(7):781-792. doi:10.1001/jamapediatrics.2025.1066

5. Mayo Clinic Staff. Nirmatrelvir and ritonavir (oral route). Mayo Clinic. Last Updated October 1, 2025. Accessed October 20, 2025. https://www.mayoclinic.org/drugs-supplements/nirmatrelvir-and-ritonavir-oral-route/description/drg-20528231

6. Sawano M, Bhattacharjee B, Caraballo C, et al. Nirmatrelvir-ritonavir versus placebo-ritonavir in individuals with long COVID in the USA (PAX LC): a double-blind, randomised, placebo-controlled, phase 2, decentralised trial. Lancet Infect Dis. 2025;25(8):936-946. doi:10.1016/S1473-3099(25)00073-8

7. Geng LN, Bonilla H, Hedlin H, et al. Nirmatrelvir-ritonavir and symptoms in adults with postacute sequelae of SARS-CoV-2 infection: The STOP-PASC randomized clinical trial. JAMA Intern Med. 2024;184(9):1024-1034. doi:10.1001/jamainternmed.2024.2007

8. Stancil SL, Abdel-Rahman S, Wagner J. Developmental considerations for the use of naltrexone in children and adolescents. J Pediatr Pharmacol Ther. 2021;26(7):675-695. doi:10.5863/1551-6776-26.7.675.