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FAQs on COVID-19 in Obesity or Metabolic Syndrome
FAQs: Preventing COVID-19 in the Setting of Obesity or Metabolic Syndrome

Released: August 22, 2023

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Key Takeaways
  • Adverse effects of oral antiviral medications are rarely the cause for discontinuation.
  • Some HCPs use antivirals off label to treat people with long COVID—an indication currently being studied for efficacy and safety in STOP-PASC.
  • Although the keto diet provides a direct impact on one’s appetite, there is no evidence suggesting it has a positive effect against a viral infection like COVID-19 in humans.

Three multidisciplinary expert faculty members answer frequently asked questions about best practices and strategies for mitigating risks in people with metabolic syndrome or obesity and COVID-19. Want to learn more? Join us August 23 when experts discuss how to reduce the risk of severe COVID-19 and long COVID in individuals with obesity or metabolic syndrome. 

Are there any COVID-19 treatment-related adverse effects related to antiviral medicines that healthcare professionals (HCPs) need to discuss with patients?

Renslow Sherer, MD:
For nirmatrelvir and ritonavir in the treatment of COVID-19, it is recommended that patients take their dose with food. Ritonavir is known to be associated with early satiety or abdominal fullness and distension, which can lead to mild nausea. Of note, patients have reported a metallic and unusual taste that accompanies these medications. These adverse effects should be addressed with patients, and fortunately, they are rarely a reason for discontinuation.

For IV remdesivir, there are few reported significant adverse effects, so that treatment is well tolerated.

Should we treat long COVID with antivirals like we do with suppressive therapy to treat herpes simplex virus?

Rasika Karnik, MS, MD:
Although there is no indication for the use of antivirals to treat long COVID, it is currently being studied. Researchers in STOP-PASC—a 3-week, randomized, double-blind phase II clinical trial—are analyzing if nirmatrelvir plus ritonavir will decrease symptoms of long COVID. I have had patients tell me that they tried this combination elsewhere and reported mixed results. But the STOP-PASC trial is critical to understanding these medications and their safety profile in treating long COVID symptoms. If HCPs are going to prescribe this treatment to patients for an extended period of time, we first need to know if it actually will help. 

How should we treat unvaccinated patients with acute COVID-19 and long COVID? Should they be vaccinated?

Rasika Karnik, MS, MD:
First, I would talk to the patients about COVID-19 vaccination to see if they are willing to take it. Much of the evidence suggests that vaccination can help, but it may also result in no change at all. Further, there are some data suggesting that patients may feel worse after vaccination. I think the guiding principle here is truly ruling out any underlying medical conditions to ensure nothing will negatively affect the patient after vaccination.

In treating long COVID, HCPs should have a detailed discussion with patients to understand and identify their symptoms. For example, shortness of breath may be more closely associated with systemic disease, and palpitations may be a result of postural tachycardia syndrome rather than COVID-19. 

HCPs need to determine which symptom is bothering patients the most and treat that symptom with what they know. I have seen fatigue as one of the biggest problems for patients with long COVID-19, and there are some off-label uses of drugs like naltrexone or stimulants that may help.

Enrolling individuals on long COVID clinical trials, such as those through the National Institutes of Health’s RECOVER Initiative, is also a wonderful opportunity for those interested. These will provide the objective data we need to measure outcomes, ultimately allowing HCPs to help more patients.

Would you suggest that patients adopt the ketogenic (keto) diet as a component of their severe COVID-19 infection or long COVID treatment in those who are obese?

Donna Ryan, MD:
There are several ways to induce ketosis, and one is initiating a negative energy balance in the body. If someone has a diet that is very high in fat and low in carbohydrates (the keto diet), it is possible they will hit that negative energy balance and be in ketosis. And after they exhaust their glycogen stores, they will begin metabolizing their stored fat while in that negative energy balance. I recommend this diet to some individuals and especially for children who have rare and refractory epilepsies.

For those with obesity and an acute illness/infectious disease, I do not recommend purposely putting them into a negative energy balance via their diet. Rather, I believe that HCPs need to be providing as much nutritional support as they can.

I do not see a value in adopting the keto diet to initiate the ketosis state in acute or long COVID. People like the keto diet because it often has a direct impact on appetite, but there is no evidence suggesting it has a positive effect against an acute viral infection like COVID-19.

Your Thoughts
Are you seeing your unvaccinated patients who present with severe COVID-19 or long COVID becoming more open to or ultimately being vaccinated after patient–provider discussions on its benefits? Join the conversation by adding a comment below.