I-RECOVER
LONG COVID TREATMENT
Up to 80% of patients experience prolonged illness after COVID-19, characterized by prolonged malaise, headaches, generalized fatigue, sleep difficulties, hair loss, smell disorder, decreased appetite, painful joints, dyspnea, chest pain and cognitive dysfunction. Long COVID may persist for months after acute infection, and it is likely that patients who did not receive adequate treatment during the symptomatic phase are much more likely to develop long COVID. Treatment should be individualized to clinical signs and symptoms.
The information in this document is our recommended approach to COVID-19 based on the best (and most recent) literature.
It is provided as guidance to healthcare providers worldwide on the early treatment of COVID-19. Patients should always consult with their provider before starting any medical treatment.
For more information on nutritional therapeutics and how they can help with COVID-19, visit our nutritional therapeutics guide.
For additional information on prevention, the rationale behind these medications, and other optional treatments, see An Approach to Treating Long COVID.
First Line Therapies
(Not symptom specific; listed in order of importance.)
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Prednisone: 10–15mg daily for 3 weeks. Taper to 10mg for three days, then 5mg for three days, then stop.
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Ivermectin: 0.2–0.3 mg/kg daily for 2-3 weeks.
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Low dose Naltrexone (LDN): Begin with 1 mg daily, increase to 4.5 mg daily as required.
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. -
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: The majority of those with long COVID continue to have Vitamin D deficiency. Patients may require a loading dose based on baseline Vitamin D levels (see Table 2). If baseline levels are unknown, the needed dose can be calculated from body weight or BMI (see Table 3).
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Omega-3 fatty acids: Vascepa, Lovaza or DHA/EPA; 4 g/day.
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Aspirin: 81 mg daily.
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Curcumin (turmeric): 500 mg twice daily.
Adjunctive/Second Line Therapies
(Listed in order of importance)
If symptoms do not improve after 1-2 weeks continue steroids, Omega-3 fatty acids and LDN and add second line therapies as below.
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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 behaviour. -
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 to provide 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®).
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N-acetyl cysteine (NAC): 600-1500 mg/day.
Third Line Therapies
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Maraviroc: 300mg PO twice a day.
If 6–8 weeks have elapsed and significant symptoms persist this drug can be considered. Note that maraviroc can be expensive and carries the risk of significant side effects and interactions with other medications.
Optional Adjunctive Therapies (in order of priority)
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Curcumin: 500mg BID
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.
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Behavioral modification, mindfulness therapy and psychological support may help improve survivors’ overall well-being and mental health.
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Luteolin 100–200mg day or Quercetin 250mg day (or mixed flavonoids).
Luteolin and quercetin have broad spectrum antiinflammatory 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.
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H2 receptor blockers (for mast cell activation syndrome): Famotidine 20–40mg, or Nizatidine 150mg — twice daily as tolerated.
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Montelukast: 10mg/day (for mast cell activation syndrome). Caution as may cause depression is some patients.
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Anti-androgen therapy: Spironolactone 50–100mg twice a day, and Dutasteride 1mg daily.
Table 1. How to calculate ivermectin dose
Note that ivermectin is available in different strengths (e.g., 3, 6 or 12 mg) and administration forms (tablets, capsules, drops, etc.). Note that tablets can be halved for more accurate dosing, while capsules cannot.
| How much do I weigh? | What dose does the protocol say? | ||||
|---|---|---|---|---|---|
| In pounds | In kilograms | 0.2 mg/kg: | 0.3 mg/kg: | 0.4 mg/kg: | 0.6 mg/kg: |
| 70-90 | 32-41 | 6-8 mg | 10-12 mg | 13-16 mg | 19-25 mg |
| 91-110 | 41-50 | 8-10 mg | 12-15 mg | 17-20 mg | 25-30 mg |
| 111-130 | 50-59 | 10-12 mg | 15-18 mg | 20-24 mg | 30-35 mg |
| 131-150 | 60-68 | 12-14 mg | 18-20 mg | 24-27 mg | 36-41 mg |
| 151-170 | 69-77 | 14-15 mg | 21-23 mg | 27-31 mg | 41-46 mg |
| 171-190 | 78-86 | 16-17 mg | 23-26 mg | 31-35 mg | 47-52 mg |
| 191-210 | 87-95 | 17-19 mg | 26-29 mg | 35-38 mg | 52-57 mg |
| 211-230 | 96-105 | 19-21 mg | 29-31 mg | 38-42 mg | 58-63 mg |
| 231-250 | 105-114 | 21-23 mg | 32-34 mg | 42-45 mg | 63-68 mg |
| 251-270 | 114-123 | 23-25 mg | 34-37 mg | 46-49 mg | 68-74 mg |
| 271-290 | 123-132 | 25-26 mg | 37-40 mg | 49-53 mg | 74-79 mg |
| 291-310 | 132-141 | 26-28 mg | 40-42 mg | 53-56 mg | 79-85 mg |
Table 2. How to replenish Vitamin D levels based on baseline levels
When serum vitamin D levels are available, the doses provided in this table can be used for the longer-term maintenance of serum 25(OH)D concentration above 50 ng/mL (125 nmol/L). The table provides the initial bolus dose, weekly dose, frequency, and the duration of administration of oral vitamin D in non-emergency situations, in a non-obese, 70 kg adult. *
| Baseline Vitamin D (ng/mL)** | Vitamin D dose, 50,000 IU capsules: Initial and weekly $ | Duration (Number of Weeks) | Total Amount Needed to Correct Vit. D, Deficiency (IU, in Millions)# | |
|---|---|---|---|---|
| Initial Bolus Dose (IU) | Follow-Up: $$ The Number of 50,000 IU Caps/Week | |||
| < 10 | 300,000 | x 3 | 8 to 10 | 1.5 to 1.8 |
| 11-15 | 200,000 | x 2 | 8 to 10 | 1.0 to 1.2 |
| 16-20 | 200,000 | x 2 | 6 to 8 | 0.8 to 1.0 |
| 21-30 | 100,000 | x 2 | 4 to 6 | 0.5 to 0.7 |
| 31-40 | 100,000 | x 2 | 2 to 4 | 0.3 to 0.5 |
| 41-50 | 100,000 | x 1 | 2 to 4 | 0.2 to 0.3 |
* A suitable daily or weekly maintenance dose to be started after completing the loading-dose schedule. The dose should be adjusted for those who are overweight (higher) or underweight (lower).
** To convert ng/mL to nmol/L, multiply the amount in ng by 2.5; One µg = 40 IU.
$ Mentioned replacement doses can be taken as single, cumulative doses, two to three times a week spread out over a few weeks.
$$ From the day one of week two onwards. # Estimated total vitamin D dose needed to replenish the body stores (i.e., the deficit) is provided in the last column.
(Table adapted with permission from S.J. Wimalawansa)
Table 3. How to calculate Vitamin D dose when baseline not available
Longer-term maintenance schedules of oral vitamin D based on body weight to maintain the levels above 50 ng/mL (125 nmol/L) when the serum 25(OH)D concentrations are unknown.
| Bodyweight Category | Dose kg/day (IU) | Dose (IU) (Daily or Weekly)* | ||
|---|---|---|---|---|
| (Age) or Using BMI (for age > 18) (kg/Ht. M2) | Average Body Weight (Kg) | Daily dose (IU) | Once a week (IU) | |
| (Age 1-5) | 5-13 | 70 | 350-900 | 3000-5000 |
| (Age 6-12) | 14-40 | 70 | 1000-2800 | 7000-28,000 |
| (Age 13-18) | 40-50 | 70 | 2800-3500 | 20,000-25,000 |
| BMI ≤ 19 | 50-60 (under-weight adult) |
60 to 80 | 3500-5000 | 25,000-35,000 |
| BMI < 29 | 70-90 (normal; non-obese) |
70 to 90 | 5000-8000 | 35,000-50,000 |
| BMI 30-39 | 90-120 (obese persons)# |
90 to 130 | 8000-15,000 | 50,000-100,000 |
| BMI ≥ 40$ | 140 (morbidly obese)$ |
140 to 180 | 18,000-30,000 | 125,000-200,000 |
* Example of a daily or once-a-week dose range for adults with specific body types (based on BMI for white Caucasians and body weight for other ethnic groups). Appropriate dose reductions are necessary for children.
# For those with chronic comorbid conditions, such as hypertension, diabetes, asthma, COPD, CKD, depression, and osteoporosis, and to reduce all-cause mortality, higher doses of vitamin D are needed. For them, one can use the doses that are recommended for persons with obesity (BMI, 30–39: the third row).
$ Those with multiple sclerosis, cancer, migraine headaches, and psoriasis, and those routinely taking medications such as anti-epileptic and anti-retroviral agents that significantly increase the catabolism of vitamin D should consider taking age-appropriate doses recommended for those with morbid obesity (BMI ≥ 40; the higher end of the daily doses in the fourth row).
(Table adapted with permission from S.J. Wimalawansa)
This protocol is solely for educational purposes regarding potentially beneficial therapies for COVID-19. Never disregard professional medical advice because of something you have read on our website and releases. This protocol is not intended to be a substitute for professional medical advice, diagnosis, or treatment with regard to any patient. Treatment for an individual patient should rely on the judgement of a physician or other qualified health provider. Always seek their advice with any questions you may have regarding your health or medical condition. Please note our full disclaimer at: www.flccc.net/disclaimer
Long Haul COVID Syndrome (LHCS)—commonly known as long COVID—is characterized by prolonged malaise, headaches, generalized fatigue, sleep difficulties, hair loss, smell disorder, decreased appetite, painful joints, dyspnea, chest pain and cognitive dysfunction.
Up to 80% of patients experience prolonged illness after COVID-19. Long COVID is not only seen after COVID infection but is also being observed in some people who have received vaccines (likely due to monocyte/microglia activation by the spike protein from the vaccine). Long COVID may persist for months after the acute infection and almost half of patients report reduced quality of life.
Patients may suffer prolonged neuropsychological symptoms, including multiple domains of cognition. A puzzling feature of long COVID is that it is not predicted by initial disease severity; it frequently affects mild-to-moderate cases and younger adults who did not require respiratory support or intensive care.
The symptom set of long COVID is, in the majority of cases, very similar to chronic inflammatory response syndrome (CIRS)/myalgic encephalomyelitis/chronic fatigue syndrome. An important differentiating factor from CIRS is the observation that long COVID continues to improve on its own, albeit slowly in the majority of cases.
Another important observation is that long COVID includes more young people compared to severe COVID, which affects older people or persons with co-morbidities.
Long COVID is highly heterogeneous and likely results from a variety of pathogenetic mechanisms. Furthermore, it is likely that delayed treatment (with ivermectin, etc.) in the early symptomatic phase results in a high viral load (high spike protein load), which increases the risk and severity of long COVID.
The approach outlined in the I-RECOVER: Long COVID Treatment Protocol is a consensus based on a collaboration led by Dr. Mobeen Syed (“Dr. Been”), Dr. Tina Peers, and the FLCCC Alliance. The approach should be individualized according to the patient’s clinical signs and symptoms.
As with all FLCCC protocols, aspects may change as scientific data and clinical experience in this condition evolve. Thus it is important to check back frequently to receive notification of any protocol changes.