**Background:** Post-COVID syndrome affects a substantial proportion of SARS-CoV-2 survivors, with symptoms persisting beyond 4 weeks from infection. In Serbia, over 2.4 million COVID-19 cases were confirmed by December 2022. During pandemic lockdowns, patients had limited access to family physicians, creating an opportunity for community pharmacists to fill a critical gap in post-COVID care. The Pharmaceutical Chamber of Serbia initiated the SMART Pharmacist Program to train pharmacists in evidence-based post-COVID counselling, aiming to leave no patient without pharmaceutical care.
**Methods:** This cross-sectional prospective observational study collected data from December 2021 to September 2022. Community pharmacists in Serbia were invited to participate through two online educational events organized by the SMART Pharmacist Program team. A standardized 60-symptom questionnaire targeting 14 organ systems was developed based on literature review and piloted by five pharmacists. Pharmacists recruited patients presenting with post-COVID symptoms; inclusion criteria followed NICE guidelines for post-COVID conditions (symptoms ≥4 weeks after confirmed COVID-19). During the first visit, pharmacists recorded demographic data, symptom duration, and patient self-reported severity on a 1-5 scale. Based on symptoms and severity, pharmacists recommended evidence-based self-medication (referencing national guidelines, WHO rehabilitation guidance, and OTC formularies) or referred patients to family physicians when indicated. Follow-up visits were scheduled at 3-4 weeks, reassessing symptom severity and treatment adherence. Statistical analysis used Kolmogorov-Smirnov tests, Mann-Whitney U tests, Kruskal-Wallis tests, Chi-square tests, and Wilcoxon signed-rank tests, with p ≤ 0.05 considered significant.
**Key Results:** Of 6980 registered community pharmacists in Serbia, 441 attended the first and 678 the second educational event; 53 pharmacists (who attended at least one event) returned completed questionnaires on 871 patients. The patient cohort was 62% female with a mean age of 45 years; males were significantly older than females. The most frequently reported symptom categories were respiratory system (51.2%), immunity status (32.2%), fatigue and exhaustion (30.7%), cognitive functions (27.9%), and skin/hair/nail changes (27.4%). Specific symptoms included cough (34%), fatigue/weakness (27%), loss of smell (25%), loss of taste (22%), loss of energy (21%), and hair loss (19%). A total of 26.5% of patients were referred to their family physician, and 69.5% returned for follow-up. On the first visit, median symptom severity was 3; on the second visit, it dropped to 1. Significant reductions (p < 0.001) were observed across most symptom categories. For loss of smell/taste, the median severity reduction was 2 levels, with alpha lipoic acid and olfactory retraining as most recommended interventions. Cough was successfully managed with OTC antitussives, mucolytics, and herbal syrups in over 50% of cases. Gastrointestinal symptoms showed significant improvement (p < 0.001) across all age groups with probiotic supplementation. Vital sign abnormalities (pulse, oxygen saturation, paraesthesia) showed significant improvement in specific age groups, with most such patients appropriately referred to physicians. Follow-up rates ranged from 64% (skin/nail changes) to 93% (autoimmunity disorders); for oldest patients with paraesthesia or impaired oxygen saturation, follow-up was 100%. Digestive system symptoms were significantly more prevalent in males; skin/hair/nail changes were more common in females. Patients aged ≥65 had significantly higher prevalence of muscle, digestive, and vital sign symptoms, and were more likely to have ≥4 concurrent symptoms (p = 0.003).
**Clinical Implications:** This study provides real-world evidence that community pharmacists, when equipped with standardized tools and evidence-based training through the SMART Pharmacist Program, can effectively identify and manage a broad spectrum of post-COVID symptoms through appropriate self-medication counselling and timely physician referrals. The high follow-up rates (64-100% depending on symptom category) suggest strong patient engagement and trust in pharmacist services. The significant reduction in symptom severity across multiple organ systems supports the integration of pharmacist-led post-COVID care into primary healthcare systems. The study also highlights that age-specific differences in symptom presentation (older patients having more muscle, digestive, and vital sign symptoms) require tailored counselling approaches. Limitations include reliance on patient-reported subjective severity scores, inability to fully isolate pharmacist intervention effects from natural recovery, lack of detailed referral outcome analysis, and no formal adherence assessment. Nevertheless, these findings advocate for expanding pharmacist roles in public health and universal health coverage initiatives, particularly during healthcare system strain such as pandemics.