Clinical practice guideline for long COVID prevention and treatment.
Cao, Bin, Soriano, Joan B, Wang, Quanyi et al. · The European respiratory journal · 2026 · DOI
Quick Summary
This guideline summarizes the best available evidence on preventing and treating long COVID (also called post-COVID syndrome). A large international team of experts reviewed research studies and patient experiences to create 10 practical recommendations for doctors. The main suggestions include using vaccines or antivirals early during acute COVID infection to prevent long COVID, avoiding certain medications that don't help, and recommending probiotics, cognitive behavioral therapy for fatigue, and rehabilitation as helpful treatments.
Why It Matters
This guideline provides the first international consensus-based framework for long COVID management, addressing a significant unmet clinical need as ME/CFS and long COVID populations lack standardized treatment protocols. The explicit recommendations against unhelpful or potentially harmful interventions protect patients from ineffective therapies, while evidence-supported suggestions offer clinicians a structured approach to care. For ME/CFS patients specifically, the emphasis on avoiding post-exertional malaise exacerbation during rehabilitation aligns with core disease understanding.
Observed Findings
• Vaccination and antiviral agents during acute COVID-19 may reduce long COVID risk
• Nirmatrelvir-ritonavir and glucocorticoids showed insufficient evidence and are not recommended for long COVID treatment
• Multi-species probiotics, cognitive behavioral therapy (specifically for fatigue), and personalized rehabilitation are supported as treatment options
• Very low to moderate certainty of evidence underlies all 10 recommendations
• Post-exertional malaise must be excluded or carefully managed during rehabilitation protocols
Inferred Conclusions
Early prevention strategies during acute COVID-19 infection appear more supported than treatments after long COVID develops.
Certain commonly-used medications do not have evidence supporting their use in long COVID and should be avoided.
Multimodal approaches combining pharmacological (probiotics) and behavioral/rehabilitative interventions show promise for symptom management.
Significant gaps in high-quality research evidence necessitate urgent investment in rigorous clinical trials.
Remaining Questions
What are the optimal protocols for personalized rehabilitation that safely avoid triggering post-exertional malaise?
What This Study Does Not Prove
This guideline does not establish that recommended treatments are highly effective—all recommendations carry very low to moderate certainty, meaning high-quality evidence is currently lacking. The guideline cannot determine causality or long-term outcomes, as it synthesizes existing literature which the authors acknowledge is often low methodological quality. It also does not prove that one-size-fits-all approaches work for all patients, as personalization and individual response variation are not fully addressed.
About the PEM badge: “PEM required” means post-exertional malaise was an explicit required diagnostic criterion for participant inclusion in this study — not that PEM was studied, observed, or discussed. Studies using criteria that do not require PEM (e.g. Fukuda, Oxford) are tagged “PEM not required”. How the atlas works →