The I-RECOVER Management Protocol for Long Haul COVID-19 Syndrome

This page was updated on December 2, 2022, with new information.

The Front Line COVID-19 Critical Care Alliance has a protocol for treating Long Haul COVID-19 Syndrome (LHCS) or Post Acute Sequelae of COVID-19 (PASC)

What is Long Haul COVID-19 Syndrome?

LHCS can happen after an acute COVID-19 or COVID-19 vaccination. The symptoms are generalized fatigue, sleeping difficulties, loss of smell, painful joints, dyspnea, chest pain, and brain fog.

LHCS can happen in mild to moderate cases of COVID-19 and affects younger adults. Delayed treatment of COVID-19 results in a high viral load will increase the likelihood of LHCS.

The approach outlined below is a consensus protocol based on a collaboration led by Dr. Mobeen Syed (“Dr. Been”), Dr. Tina Peers, and the FLCCC Alliance. It is based on the disease mechanism of LHCS.  This protocol has been used for post-vaccine inflammation syndrome successfully.

The treatment described below includes prescription medicines and nutritional supplements. Talk to your doctor if you have the symptoms of LHCS and refer them to the FLCCC I-Recover Management Protocol Webpage. The is a downloadable PDF file of the protocol available at this LINK. 

The initial therapy of LHCS includes

• Prednisone: 10–15mg daily for three weeks. Taper to 10mg for three days, then 5mg for three days, then stop.

• Ivermectin: 0.2–0.3 mg/kg daily for 2-3 weeks. Know the amount of ivermectin you need based on your weight at table 1 on this LINK.

• Low dose Naltrexone (LDN): Begin with 1 mg daily, increase to 4.5 mg daily as required.
  It may take 2-3 months for full effect.

• Intermittent daily fasting and/or periodic daily fasts:
  Fasting promotes autophagy, the body’s protective mechanism to remove misfolded, foreign, and damaged proteins. It also promotes mitophagy and the release of stem cells. It is likely that promoting autophagy will aid in the removal of the spike protein. NOTE: Hydroxychloroquine inhibits autophagy and should be avoided in patients undergoing intermittent fasting.

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• Spermidine and/or Resveratrol:
  These compounds have been demonstrated to augment autophagy. Wheatgerm, mushrooms, grapefruit, apples, and mango are high natural sources of spermidine. A bio-enhanced formulation containing trans-resveratrol from Japanese Knotwood Root appears to have good bio-availability

• Melatonin: 8 mg at night (slow release/extended release preferred).
  Patients should pay attention to good sleep habits. Increase dose from 1 mg as tolerated (may cause severe bad dreams at high dosages).

• Vitamin D: Most of those with long COVID continue to have Vitamin D deficiency. Know the dose of Vitamin D you need based on the baseline vitamin D level in Table 2 at this LINK. If you don’t have a baseline Vitamin D level, use Table 3 on the same LINK.

• Omega-3 fatty acids: Vascepa, Lovaza, or DHA/EPA; 4 g/day.

• Aspirin: 81 mg daily.

• Curcumin (turmeric): 500 mg twice daily.

  Second Line Therapies

  If symptoms do not improve after 1-2 weeks, continue steroids, Omega-3 fatty acids, and LDN and add second-line therapies as below.

  • Fluvoxamine: 50 mg twice daily
    Start on a low dose of 12.5 mg/day and increase slowly as tolerated. Stop if the symptoms increase. Caution with the use of other antidepressants and psychiatric drugs. Taper and discontinue once symptoms improve. NOTE: Some individuals who are prescribed fluvoxamine experience acute anxiety, which needs to be carefully monitored for and treated by the prescribing clinician to prevent rare escalation to suicidal or violent behavior.

  • Atorvastatin: 20–40mg once daily.
    Caution in patients with Postural Orthostatic Tachycardia Syndrome (POTS); may exacerbate symptoms.

  • Hydroxychloroquine (HCQ): 200 mg twice daily for 1-2 weeks, then reduce as tolerated to 200 mg daily.
    HCQ is the preferred second-line agent. With long-term usage, the dose should be reduced (100 mg or 150 mg daily) in patients weighing less than 61 kg (135 lbs).

  • Intravenous Vitamin C: 25 g/week, together with oral Vitamin C 1000 mg (1 gram) 2-3 times daily.
    Oral Vitamin C is important in providing nutrients for the microbiome. Total daily doses of 8-12 g have been well-tolerated. However, chronic high doses have been associated with the development of kidney stones, so the duration of therapy should be limited. Wean IV Vitamin C as tolerated.

  • Mitochondrial energy optimizer with pyrroloquinoline quinone (e.g., Life Extension Energy Optimizer or ATP 360®).

  • N-acetyl cysteine (NAC): 600-1500 mg/day.

  Third Line Therapies

  • Maraviroc: 300mg PO twice a day.
    This drug can be considered if 6–8 weeks have elapsed and significant symptoms persist. Note that maraviroc can be expensive and carries the risk of significant side effects and interactions with other medications.

4. Optional Adjunctive Therapies (in order of priority)

• Curcumin: 500mg BID
  It has anti-inflammatory and immunomodulating properties and has been demonstrated to repolarize macrophages.

• Nigella Sativa: 40mg/kg/day (1tsp ≈ 3.3grams)
  like curcumin, it has anti-inflammatory and immunomodulating properties.

• Vitamin C: 500mg BID
  vitamin C inhibits histamine and repolarizes monocytes.

• Melatonin: 2–8mg at night (slow release/extended release)
  with attention to sleep hygiene. Increase dose from 1mg as tolerated (may cause severe nightmares at high dosages).

• Kefir, probiotic yogurt, and/or Bifidobacterium Probiotics (e.g., Daily Body Restore) together with Prebiotics (e.g., XOS Prebiotic, Bio Nutrition Pre-Biotic) to normalize the microbiome. Prolonged dysbiosis has been reported following COVID-19 infection.

• Behavioral modification, mindfulness therapy, and psychological support may help improve survivors’ overall well-being and mental health.

• Luteolin 100–200mg day or Quercetin 250mg day (or mixed flavonoids).
  Luteolin and quercetin have broad-spectrum anti-inflammatory properties. These natural flavonoids inhibit mast cells and have been demonstrated to reduce neuroinflammation.

• H1 receptor blockers (for mast cell activation syndrome): Loratadine 10mg daily, or Cetirizine 5–10mg daily, or Fexofenadine 180mg — daily.

• H2 receptor blockers (for mast cell activation syndrome): Famotidine 20–40mg or Nizatidine 150mg — twice daily as tolerated.

• Montelukast: 10mg/day (for mast cell activation syndrome). Caution: may cause depression in some patients.

• Anti-androgen therapy: Spironolactone 50–100mg twice a day, and Dutasteride 1mg daily

Check the FLCCC website regularly to check for updates. The protocol may change as more data about the treatment for LHCS come forward.

Knowledge about Covid-19 is rapidly evolving. Information may update as new studies are made. Stay current by subscribing. Feel free to share and like.

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