I-Recover: FLCCC Long Haul Protocol 2022

The Long Haul COVID-19 Syndrome (LHCS) is a syndrome characterized by symptoms such as prolonged malaise, headaches, generalized fatigue, sleep difficulties, smell disorder, decreased appetite, painful joints, dyspnea, chest pain and cognitive dysfunction.
I-Recover protocol
Up to 80% of patients experience prolonged illness after COVID-19. LHCS (Long Haul COVID Syndrome) is not only seen after the COVID infection but it is being observed in some people that have received vaccines. 

A puzzling feature of the LHCS syndrome is that it is not predicted by initial disease severity; post-COVID-19 frequently affects mild-to-moderate cases and younger adults that did not require respiratory support or intensive care.

The symptom set of LHCS in the majority of cases is very similar to the chronic inflammatory response syndrome (CIRS)/myalgic encephalomyelitis/chronic fatigue syndrome, although in LHCS, symptoms tend to improve slowly in the majority of the cases. Furthermore, the similarity between the mast cell activation syndrome and LHCS has been observed, and many consider post-COVID-19 to be a variant of the mast cell activation syndrome. LHCS is highly heterogenous and likely results from a variety of pathogenetic mechanisms. Furthermore, it is likely that delayed treatment (with ivermectin) in the early symptomatic phase will result in a high viral load, which increases the risk and severity of LHCS.

Although numerous reports describe the epidemiology and clinical features of LHCS, studies evaluating treatment options are glaringly sparse. Indeed, the NICE guideline for managing the long-term effects of COVID-19 provide no specific pharmacologic treatment recommendations.

Given the lack of available treatment recommendations in the setting of large numbers of patients suffering with this disorder globally, the FLCCC developed the I-RECOVER protocol in collaboration with a number of expert clinicians including Dr. Mobeen Syed, Dr. Ram Yogendra, Dr. Bruce Patterson, and Dr. Tina Peers. Although our varied yet often overlapping treatment approaches were initially empiric, while based on both preliminary investigations into and prevailing theoretical pathophysiologic mechanisms of LHCS, the consistently positive clinical responses observed, often profound and sustained, led the collaboration to form the consensus protocol below. As with all FLCCC protocols, we must emphasize that multiple aspects of the protocol may change as scientific data and clinical experience in this condition evolve, thus it is important to check back frequently or join the FLCCC Alliance to receive notification of any protocol changes.

NB: A syndrome is not a disease. It’s a group of signs and symptoms that may accompany more than one specific disease. In this case, the syndrome affects some people who have contracted the virus that causes COVID-19 and can mimic the symptoms of other, seemingly unrelated diseases.

I-Recover Protocol (updated June 16, 2021)

The approach outlined below is a consensus protocol based on a collaboration led by Dr. Mobeen Syed (“Dr. Been”), Dr. Ram Yogendra, Dr. Bruce Patterson, Dr. Tina Peers, and the FLCCC Alliance. Given the lack of clinical treatment trials of Long Haul COVID-19 Syndrome, these recommendations are based on the anomalies within the body associated with COVID-19 and post-viral illnesses along with our collective experience observing profound and sustained clinical responses achieved with the treatment approaches below. This protocol has also been used to treat post-vaccine inflammatory syndromes with similar success. As with all FLCCC Alliance protocols, the components, doses, and durations will evolve as more clinical data accumulates. For the most up-to-date information on optional treatments, go to: flccc.net/flccc-protocols-a-guide-to-the-management-of-covid-19 (see LHCS section).

IVERMECTIN (Initial therapy of Long Haul COVID-19 Syndrome):

0.2–0.4mg/kg dose – once daily with meals* for 3–5 days (higher doses are sometimes needed in anosmia). 
* Take on empty stomach if presenting with nausea/diarrhea/anorexia. 
After 3–5 days, change to once or twice weekly depending on the time to symptom recurrence/persistence. 
Discontinue after 2–4 weeks if all symptoms have resolved and do not recur. Relative Contraindications: 
– Patients on Warfarin require close monitoring and dose adjustment. 
– Pregnant or lactating women require a more in-depth risk/benefit assessment.

CORTICOSTEROID THERAPY (If not all symptoms resolve with ivermectin):

A tapering dose of prednisone as follows: 
1. 0.5mg/kg daily for 5 days 
2. 0.25mg/kg daily for 5 days 
3. 0.12mg/kg daily for 5 days 
Take in morning to lessen impact on sleep. 
Side effects may include: Increased appetite, mood changes, insomnia, raised blood glucose, dyspepsia.

FLUVOXAMINE (If presenting with neurologic symptoms, i.e. poor concentration, forgetfulness, mood disturbance):

50mg – twice daily for 15 days. 
Reduce dose or discontinue if side effects develop. Doses as low as 9mg twice daily have shown efficacy. 
Monitor closely as some patients may respond poorly. Some individuals can experience acute anxiety; monitor and treat carefully to prevent rare escalation to suicidal or violent behaviour.

TREATMENT OF SUSPECTED MAST CELL ACTIVATION (If symptoms still unresolved or recur after ivermectin and corticosteroid regimens):

Choose a Type I and a Type II antihistamine along with a mast cell stabilizer – for example, Loratadine, Famotidine, and Rupatadine. Change medicines if poor response. United States FDA approved doses of many of the below medicines are once daily but can use up to three times daily with caution and close monitoring if poor response or side effects. 

First-line Therapy 
  • Low histamine diet 
  • Type l antihistamines: Loratadine 10mg, or Cetirizine 10mg, or Fexofenadine 180mg – three times daily as tolerated. 
  • Type ll antihistamines: Famotidine 20mg, or Nizatidine 150mg – twice daily as tolerated. 
  • Mast cells stabilizers: – Rupatadine 10mg – once daily, or Ketotifen 1mg – once daily at night (increase as tolerated). – May add: Sodium Cromoglycate 200mg – three times daily (increase slowly), or Quercetin 500mg – three times daily. 
Second-line Therapy 
  • Montelukast 10mg (beware depression in some) – once daily. 
  • Low Dose Naltrexone (LDN) – start with 0.5mg daily, increasing by 0.5mg weekly up to 4.5mg daily. Avoid if on opiates. 
  • Diazepam 0.5–1mg twice daily. 
  • SSRIs.
MACROPHAGE/MONOCYTE REPOLARIZATION THERAPY (For use in all patients):

Vitamin C — 500mg twice daily 
Omega-3 Fatty Acids — 4gm/daily (Vascepa, Lovaza, or DHA/EPA) 
Melatonin — 2–10mg nightly, start with low dose, increase as tolerated in absence of sleep disturbance. 
Atorvastatin (Lipitor) — 40mg daily 
Additional Supplement: Vitamin D3 — 2,000–4,000 IU daily



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