COVID-19-induced gastrointestinal autonomic dysfunction: A systematic review

Table 8 Treatment of gastrointestinal autonomic dysfunction in patients with coronavirus disease 2019

Treatment	Comments
Infection control measures	To prevent the spread of COVID-19, following the public health guidelines, such as social distancing, wearing a face mask, and practicing ‎good hand hygiene
Treatment of COVID-19	Treatment of COVID-19 should be made on a case-by-case basis, based on the severity of COVID-19 and the patient's overall health status
	Antiviral therapy such as Remdesivir and Molnupiravir, could be used in patients with COVID-19 to reduce the severity and duration of the illness. However, there is limited evidence for the effectiveness of antiviral therapy for COVID-19-induced gastrointestinal autonomic dysfunction
	Immunomodulatory therapy in severe cases of COVID-19-induced gastrointestinal autonomic dysfunction, such as corticosteroids or monoclonal antibodies such as Tocilizumab, may be needed to reduce inflammation and prevent complications
	Oxygen therapy may be needed
	Manage any other COVID-19-related complications that may arise
Supportive management	ORT, intravenous fluids, and electrolyte replacement therapy
	Getting enough rest is crucial to enhance recovery
Symptomatic treatment	Management for abdominal pain with antispasmodics and analgesics such as acetaminophen or nonsteroidal anti-inflammatory drugs. Avoid using anticholinergics or opioids, as they can exacerbate gastrointestinal autonomic dysfunction
	For nausea and vomiting: Antiemetic and prokinetics such as ondansetron or metoclopramide
	For diarrhoea: Antidiarrheals such as loperamide or bismuth subsalicylate
	Constipation: Laxatives
	Caution should be taken as symptomatic treatment may mask underlying symptoms of COVID-19
Managing autonomic dysfunction	Using medications such as alpha-adrenergic agonists, beta-blockers, or anticholinergic medications to regulate the autonomic nervous system, depending on the specific symptoms and severity of autonomic dysfunction. However, these medications must be used cautiously, as they can induce side effects and interact with other medications. Specific treatment for orthostatic hypotension, tachycardia, and syncope should be according to the guidelines
Treatment of complications	Treatment of dehydration and electrolyte imbalances, especially in children and the elderly
	Treatment of gastroparesis: Prokinetic agents, such as erythromycin or metoclopramide, may be needed to promote gastric emptying, improve gastrointestinal motility, relieve gastroparesis symptoms, and relieve symptoms of constipation
	Treatment of malnutrition
	Treatment of bowel obstruction or perforation: Surgical management
	Treatment of bacterial superinfections and/or sepsis
	Severe disease may may require ICU admission, mechanical ventilation, or ECMO support
Treating underlying conditions	IBD: Anti-inflammatory drugs, immunosuppressants such as corticosteroids, immunomodulators, biologic therapies, and antibiotics with adjustments to their regular treatment regimen or referral to a specialist. Diet modifications by avoiding trigger foods that exacerbate symptoms may help manage IBD symptoms. A low FODMAP diet may be beneficial for some people with IBD. Stress management and regular exercise could help. Surgery may be indicated in severe cases
	IBS: Diet modifications medications such as antispasmodics, laxatives, and antidepressants to help alleviate symptoms, probiotics, stress management, and regular exercise
	Malignancy therapy should be personalized according to the type of malignancy by surgery, chemotherapy, radiotherapy, palliative therapy, immunomodulators, and supportive care
Nutritional support	Maintain adequate caloric intake, prevent malnutrition, follow a bland diet, and avoid spicy, fatty, or acidic foods that may worsen symptoms
	Nutritional support may be necessary for patients with decreased appetite or weight loss
	Nutritional supplements or enteral or parenteral nutrition according to the situation
	Probiotics positively affect the gut microbiota, improving gut dysbiosis that is common in gastrointestinal disorders and helping improve gastrointestinal symptoms such as bloating, constipation, and diarrhea. Prebiotics promote the growth of beneficial gut bacteria, which can improve gut health and potentially alleviate the associated symptoms. The optimal dosage, duration, and strains of probiotics/prebiotics could differ depending on the patient’s characteristics and the underlying pathophysiology of gastrointestinal autonomic dysfunction
Psychological support	Treatment of psychological distress induced by the symptoms of gastrointestinal autonomic dysfunction
	Psychological support, such as counseling or psychotherapy
Follow-up and Rehabilitation care	Regular check-ups with a healthcare professional may be necessary depending on the severity of the condition
	Aiming to monitor the resolution of symptoms, prevent long-term complications, and improve the patient's quality of life and functional status
	Rehabilitation may include occupational therapy, physical therapy, speech therapy, and psychological support to manage potential complications and improve the overall quality of life
	Physical therapy can help manage autonomic dysfunction symptoms, including gastrointestinal symptoms. Physical activities such as postural changes and deep breathing exercises can facilitate improved blood flow and reduce the symptoms

COVID-19: Coronavirus disease 2019; ECMO: Extracorporeal membrane oxygenation; FODMAP: Fermentable oligo-, di-, and monosaccharides and polyols; IBD: Inflammatory bowel disease; IBS: Irritable bowel syndrome; ICU: Intensive care unit; ORT: Oral rehydration therapy.