With nirmatrelvir-ritonavir now tested and negative, management returns to the phenotype in front of you. For post-exertional malaise, pacing is the intervention: graded exercise that ignores symptom crashes can make it worse. For orthostatic symptoms, check a 10-minute active stand for postural tachycardia and start with fluids, salt and compression. For cognitive symptoms, screen for sleep disorder, depression and medication effects.
None of this is curative. It is the difference between a patient who feels abandoned and one who has a plan.
- Ask about post-exertional malaise before prescribing exercise.
- Do an active stand test for suspected postural tachycardia.
- Screen for sleep disturbance, low mood and sedating medicines.
- Avoid unproven antiviral or anticoagulant courses.
Why it matters
Patients still need a plan when the leading drug hypothesis fails.
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