The Front Line Covid-19 Critical Care Alliance is a group of critical care physicians experienced managing severe COVID-19 patients. On August 5, 2020, they published a scientific review about the MATH+ Protocol for use among hospitalized COVID-19 patients.
The MATH+ COVID-19 Early Intervention Treatment Protocol uses intravenous methylprednisolone, ascorbic acid, heparin, thiamine, and ivermectin. The plus is for Zinc and Vitamin D.
The management also includes guidance for low oxygen management to lessen mechanical ventilators’ use to prevent lung injury.
Early treatment calls for aggressive medical intervention as soon as the diagnosis is made in the emergency room and does not wait until the patient crashes and needs an intensive care bed.
During these pandemic times, COVID-19 patients self -triage themselves. Those who go to the emergency rooms are the ones that have worse symptoms.
Mortality Rates of COVID-19 Patients Treated with MATH+
The United Memorial Medical Center in Houston, Texas, and the Sentara Norfolk General Hospital in Norfolk, Virginia, use the MATH+ protocol for admitted patients with COVID-19. These two hospitals have the lowest mortality of COVID-19 patients at 5.1%.
The other hospitals in the U.S., the U.K., and China have average mortality rates in other hospitals at 22.9%.
The average hospital mortality at these two centers as of July 15, 2020, in over 300 patients treated was 5.1 %, which represents more than a 75 % absolute risk reduction in mortality compared to the average published hospital mortality of 22.9 % among COVID-19 patients in multiple countries across the world.
A table from the review comparing the mortality rates among different studies is shown below.
Based on their success, The Math+ Protocol was formulated by the Front Line Covid-19 Critical Care Alliance.
The FLCC Alliance is composed of several physicians specializing in critical care who are well-published in their fields.
The MATH+ COVID-19 Early Intervention Protocol
MATH +
I. Intravenous Methylprednisolone
II. High dose intravenous Ascorbic acid
III. Full dose low molecular weight Heparin
IV. PLUS optional treatment components: Thiamine, Zinc and Vitamin D
Treatment of Low Oxygen
I. If the patient has low oxygen saturation on the nasal cannula, initiate heated high flow nasal cannula
- Do not hesitate to increase flow limits as needed
- Avoid early intubation that is based solely on oxygen requirements. Allow “permissive hypoxemia” as tolerated.
- Intubate only if the patient demonstrates excessive work of breathing
- Utilize “prone positioning” to help improve oxygen saturation
Why are there no Antivirals in the MATH+ Protocol?
The organ damage in Severe COVID-19 is secondary to the dysregulated hyperactive immune response against the SARS-COV-2, resulting in a hyperinflammatory state. The SARS-CoV-2 does not directly cause it.
One reason for the dysregulation is the production of free radicals and the lack of anti-oxidants in the infection’s initial stages. The lack of anti-oxidants allows the persistence of large amounts of free radicals produced in the disease’s beginning stages.
Free radicals are formed in many processes. The first is when the white blood cells or WBCs go to the virus (chemotaxis). The second is then they eat them (phagocytosis). And third is when the WBCs with the phagocytosed virus die (apoptosis).
If adequate anti-oxidants are present, no excess free radicals are formed, and the immune system works just fine. If not, the immune system goes awry.
The other problem with uncontrolled free radical formation is that it begets more free radicals and further instability.
Effects of Excessive Free-Radicals
A large amount of free radicals interferes with the immune response and contributes to the cytokine storm. Cytokine storms cause excessive inflammation and a hypercoagulable state.
Excessive inflammation can directly destroy the cells of internal organs like the heart, lungs, and blood vessels. That is why a steroid anti-inflammatory like methylprednisolone is used.
Another effect of the cytokine storm is a hypercoagulable state.
A hypercoagulable state is a condition where blood clots form easily in the blood vessels. These clots obstruct blood flow, oxygen supply, and nutrients to many organs.
Lack of blood supply to the already damaged organs contributes to multi-system organ failure common in severe COVID-19. That is why there is a need for aggressive anticoagulant therapy in the form of enoxaparin.
Vitamin C Neutralizes Excess Free Radicals
Vitamin C or ascorbic acid and zinc are readily available and inexpensive sources of anti-oxidants. Early administration of Vitamin C and zinc reduces the free radicals and ensures that the body’s immune system will take care of the SARS-CoV-2 viruses.
This removes the need for antivirals. Read more about the effects of Vitamin C on infections on this link.
The figure shown below is from the study. The orange triangle indicates that the cytokine storm gets worse as viral replication decreases. This indicates that the hyperactive immune response is not associated with the amount of SARS-CoV-2 in the body.
Note that the viral replication slowly decreases in the Symptomatic phase. As the Early Pulmonary Phase begins, there is no more viral replication.
The figure below shows that the Early and Late Pulmonary phase symptoms are due to immune dysregulation.
The Fundamental Concepts of MATH+
According to Dr. Paul Marik, the MATH+ protocol follows three principles:
- COVID-19 is not a typical ARDS or Acute Respiratory Distress Syndrome. If the patients are intubated early and hooked on the ventilator, their lungs can get damaged.
- COVID-19 produces a profound hyperinflammatory state. This is seen on the chest x-ray or C.T. scan as ground-glass opacities. It is not the virus that is damaging the host but the acute hyperinflammatory response. That makes anti-inflammatory drugs like methylprednisolone necessary.
- COVID-19 patients are in a hypercoagulable state. Blood clots very quickly inside the blood vessels. That is why an anticoagulant like enoxaparin is used.
- Ivermectin is useful in all phases of COVID-19 because it prevents SARS-COV-2 replication and is also an anti-inflammatory.
Resources:
- For a downloadable pdf file of the MATH+ Protocol of the Eastern Virginia Medical School developed by Dr. Paul Marik, click this link. EVMS CRITICAL CARE COVID-19 MANAGEMENT PROTOCOL
- The FLCC Alliance MATH+ Protocol in several languages.
- If you already use the MATH+ Protocol and want to join the worldwide alliance, click here.
- You can find the medical evidence about the MATH+ Protocol for COVID-19 here.
Related Reads:
- An update to the I-MASK+ Prevention & Early Outpatient Treatment Protocol for COVID-19
- The I-RECOVER Management Protocol for Long Haul COVID-19 Syndrome
- The I-MASK+ for the Prophylaxis and Early Treatment Protocol of COVID-19
- The MATH+ Protocol Results in Greater Survival in Hospitalized COVID-19 Patients
- Vitamin C and COVID-19
- Zinc Deficiency Impairs the Immune System
- The Updated List of COVID-19 Articles
- Blood Clot formation after COVID Vaccination
- Deadly Autoimmune Antibodies
- COVID-19, Autoimmunity, and Vaccination Part 3
- The Long COVID-19 Syndrome and What to Do About It
- The I-MASK+ for the Prophylaxis and Early Treatment Protocol of COVID-19
- COVID-19, Autoimmunity, and Vaccination Part 2
- 60% may already have Immunity to COVID-19
- Molecular Mimicry between the SARS-CoV-2 and the Breathing Center
- COVID-19, Autoimmunity, and Vaccination Part 1
- Platelet Changes Causes Blood Clots in COVID-19 talks about how COVID-19 changes the platelets to create a hypercoagulable state.
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