Front Line Doctors Ivermectin Protocol for Prevention and Treatment of COVID-19 (October 2022)

The Front Line COVID-19 Critical Care (FLCCC) Alliance was initially formed as a working group during the early COVID-19 pandemic days in response to multiple early reports of COVID patients with an inexplicably high need for prolonged mechanical ventilation and an excessive death rate. 

Based on rapidly emerging clinical trials evidence, the FLCCC team has developed the I-MASK+ protocol (is now divided into I-Prevent and I-Care protocols) for prophylaxis and at home treatment of early stage COVID-19. Quercetin, zinc and a number of nutrients and drugs are part of this protocol, not only for critical care but also for prophylaxis and mild disease being treated at home. This article, we will dive deeper to provide the scientific background, related references and rationale of the FLCCC protocols.

I-CARE COVID Treatment Protocol for Outpatients

FLCCC (Front Line COVID-19 Critical Care) Protocols

I-PREVENT Protocol

The I-Prevent protocol has been updated several times and below is their latest version (version 2: September 6, 2022).

The protocol is divided into two parts: Chronic prevention and Post-exposure prevention.
  • Chronic prevention is especially recommended for healthcare workers, those over 60 years old with co-morbidities, people who are morbidly obese, and residents of long-term care facilities. 
  • Follow post-exposure prevention if a household member is COVID-positive or if you have had prolonged exposure to COVID but have not developed symptoms. 

CHRONIC PREVENTION (In order of priority; not all required)

  • Ivermectin: 0.2 mg/kg – start treatment with one dose, take second dose 48 hours later, then 1 dose every 7 days (weekly). Those at high risk of contracting COVID-19 can consider dosing twice a week. See Table 1 for help with calculating correct dose. Due to a possible interaction between quercetin and ivermectin, these drugs should be staggered throughout the day. For COVID treatment, ivermectin is best taken with a meal or just following a meal, for greater absorption. 
  • Zinc: 30-40 mg daily. Zinc supplements come in various forms (e.g., zinc sulfate, zinc citrate and zinc gluconate). 
  • Melatonin: Begin with 1 mg and increase as tolerated to 6 mg before bedtime (causes drowsiness). Slow- or extended-release formulations preferred. 
  • Mouthwash: three times a day. Gargle three times a day (do not swallow) with an antiseptic-antimicrobial mouthwash containing chlorhexidine, cetylpyridinium chloride (e.g., Scope™, Act™, Crest™) or povidone-iodine (e.g. Betadine® Antiseptic Sore Throat Gargle™).
  • Steam inhalation: once a day. Inhaled steam supplemented with antimicrobial essential oils (e.g., Vicks VapoRub™ inhalations) has been demonstrated to have virucidal activity. Antimicrobial essential oils include lavender, thyme, peppermint, cinnamon, eucalyptus and sage. 
  • Vitamin D: dosing varies (see tables below). Vitamin D supplementation is likely a highly effective and cheap intervention to lessen the impact of this disease, particularly in vulnerable populations, (i.e., the elderly, obese, people of color, and those living in northern latitudes). The greatest COVID protection benefit from Vitamin D supplementation will occur in individuals deficient in Vitamin D. Those individuals should take Vitamin D prophylactically on a longer-term basis. When a person with Vitamin D deficiency develops COVID-19, risks increase for developing complications, and Vitamin D supplementation subsequent to infection will have less of a response. Dosing recommendations for Vitamin D supplementation vary widely. The optimal target is over 50 ng/ml; at this level the risk of dying from COVID-19 is extremely reduced. It may take many months or years to achieve optimal levels in patients who are extremely Vitamin D deficient. It is therefore important that the optimal regimen for Vitamin D supplementation for the prophylaxis of COVID-19 is provided promptly, 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).
  • Curcumin (turmeric): 500 mg twice a day. Curcumin has low solubility in water and is poorly absorbed by the body; consequently, it is traditionally taken with full fat milk and black pepper, which enhance its absorption. 
  • Nigella sativa (black cumin): 80 mg/kg daily and Honey 1 g/kg daily. Note: thymoquinone (the active ingredient of Nigella sativa) decreases the absorption of cyclosporine and phenytoin. Patients taking these drugs should therefore avoid taking Nigella sativa. 
  • Vitamin C: 500-1000 mg twice a day. 
  • Quercetin (or a mixed flavonoid supplement): 250-500 mg daily. Due to a possible interaction between quercetin and ivermectin, these drugs should not be taken simultaneously (i.e., should be staggered at different times of day). As supplemental quercetin has poor solubility and low oral absorption, lecithin-based and nanoparticle formulations are preferred.
  • Probiotics. Low levels of Bifidobacterium may predispose a person to COVID-19 and increase disease severity. Likewise, COVID-19 depletes the microbiome of Bifidobacterium, which may then increase the severity and duration of symptoms. Kefir (a fermented milk drink) is high in Bifidobacterium and other probiotics that have demonstrated health benefits. Suggested probiotic supplements include Megasporebiotic (Microbiome labs), TrueBifidoPro (US Enzymes) and yourgutplus+.

Table 1. How to calculate ivermectin dose for chronic prevention
Table 1. How to calculate ivermectin dose for chronic prevention

Table 2. How to replenish Vitamin D levels based on baseline levels
Table 2. How to replenish Vitamin D levels based on baseline levels

Table 3. How to calculate Vitamin D dose when baseline not available
Table 3. How to calculate Vitamin D dose when baseline not available

POST-EXPOSURE PREVENTION

If symptoms develop, treat promptly with I-CARE protocol. If symptoms do not develop, resume chronic prevention after one week.
  • Ivermectin: 0.4 mg/kg immediately, then repeat second dose in 48 hours. See Table 1 for help calculating dose. 
  • Hydroxychloroquine (HCQ): 200 mg twice a day for 5 days. 
  • Zinc: 75-100 mg daily. 
  • Melatonin: 6 mg daily, at bedtime. 
  • Mouthwash: three times a day. 
  • Nasal spray with 1% povidone-iodine: two to three times a day. Sprays such as Immune Mist™, CoFixRx™ or IoNovo™ administered 2-3 times per day are recommended in post-exposure prophylaxis and in the early phase of COVID-19 infection. Due to low level systemic absorption, povidone-iodine nasal spray should not be used for longer than 5-7 days in pregnant women. IoNovo™ contains iodine in an amount equivalent to the daily dietary requirement and hence is safe to ingest. 
  • Curcumin (turmeric): 500 mg twice a day for 1 week. Nigella sativa: 80 mg/kg daily for 1 week. 
  • Nigella sativa: 80 mg/kg daily for 1 week
  • Vitamin C: 1000 mg twice daily for 1 week. 
  • Quercetin: 500 mg twice daily for 1 week. 
  • Probiotics. 
  • B complex vitamins.

EARLY TREATMENT PROTOCOL (I-CARE)

The I-Care protocol has been updated several times and below is their latest version (version 3: September 6, 2022).

FIRST LINE THERAPIES (In order of priority; not all required)
  • Ivermectin: 0.4 to 0.6 mg/kg – one dose daily for at least 5 days or until symptoms resolve. If symptoms persist longer than 5 days, consult a healthcare provider. See Table 1 for help with calculating correct dose. Due to a possible interaction between quercetin and ivermectin, these drugs should be staggered throughout the day (see Table 2). For COVID treatment, ivermectin is best taken with a meal or just following a meal, for greater absorption. 
  • Hydroxychloroquine (HCQ): 200 mg twice a day for 5 to 10 days. Best taken with zinc. HCQ may be taken in place of, or together with, ivermectin. While ivermectin should be avoided in pregnancy, the FDA considers HCQ safe in pregnancy. Given the pathway used by the Omicron variant to gain cell entry, HCQ may be the preferred drug for this variant. 
  • Zinc: 75-100 mg daily. Take with HCQ. Zinc supplements come in various forms (e.g., zinc sulfate, zinc citrate and zinc gluconate). 
  • Mouthwash: three times a day. Gargle three times a day (do not swallow) with an antiseptic-antimicrobial mouthwash containing chlorhexidine, cetylpyridinium chloride (e.g., Scope™, Act™, Crest™) or povidone-iodine (e.g. Betadine® Antiseptic Sore Throat Gargle™).
  • Nasal spray with 1% povidone-iodine: 2-3 times a day. Do not use for more than 5 days in pregnancy. If 1% product is not available, dilute the more widely available 10% solution (see box) and apply 4-5 drops to each nostril every 4 hours. 
  • Aspirin: 325 mg daily (unless contraindicated). 
  • Melatonin: 5-10 mg before bedtime (causes drowsiness). Slow- or extended-release formulations preferred. 
  • Nigella sativa: If using seeds, take 80 mg/kg once a day (or 400 to 500 mg of encapsulated oil twice a day).
  • Honey: 1 g/kg one to two times a day
  • Kefir and/or Bifidobacterium Probiotics. 
  • Vitamin C: 500-1000 mg twice a day.
  • Home pulse oximeter: Monitoring of oxygen saturation is recommended in symptomatic patients, due to asymptomatic hypoxia. Take multiple readings over the course of the day and regard any downward trend as ominous. Baseline or ambulatory desaturation under 94% should prompt consultation with primary or telehealth provider, or evaluation in an emergency room.
Note: Most of the first line therapies are inexpensive and easily purchased over the counter.


SECOND LINE THERAPIES (In order of priority/importance)

Add to first line therapies above if: 
1) more than 5 days of symptoms; 
2) poor response to first line agents; 
3) significant comorbidities.
  • Nitazoxanide (NTZ): 600 mg twice a day for 5 days. 
  • Curcumin (turmeric): 500 mg twice a day. Curcumin has low solubility in water and is poorly absorbed by the body; consequently, it is traditionally taken with full fat milk and black pepper, which enhance its absorption. 
  • Quercetin (or a mixed flavonoid supplement): 250 mg twice a day. Due to a possible interaction between quercetin and ivermectin, these drugs should not be taken simultaneously (i.e., should be staggered at different times of day – see Table 2). As supplemental quercetin has poor solubility and low oral absorption, lecithin-based and nanoparticle formulations are preferred.
  • Vitamin D3: 10,000 IU daily (two 5,000 IU capsules) for two weeks. 
  • B complex vitamins
  • Fluvoxamine: 25-50 mg twice a day. Can substitute fluoxetine (Prozac; 20-40mg daily) if fluvoxamine not available. 
  • N-acetyl cysteine (NAC): 600-1200 mg orally twice a day. 
  • Omega-3 fatty acids: 4 g daily. Vascepa (Ethyl eicosapentaenoic acid); Lovaza (EPA/DHA); or alternative DHA/EPA. Vascepa and Lovaza tablets must be swallowed and cannot be crushed, dissolved, or chewed.
Table 1. How to calculate ivermectin dose
ivermectin dosage chart for humans by weight


TREATMENT OF OMICRON BA.4/BA.5 VARIANT

The following protocol should be used where BA/4/BA.5 is the predominant circulating strain. 
  • Hydroxychloroquine: (200 mg twice daily or 400 mg daily for 5 days) AND Ivermectin (0.4-0.6 mg/kg once daily for 5 days taken with a fatty meal). Alternative to ivermectin: Nitazoxanide (500 mg three times a day for 5 days taken with a fatty meal). 
  • Zinc: (75-100 mg for 5 days). 
  • Antiseptic/antimicrobial mouthwash: (3 times daily). 
  • Nasal spray with 1% povidone-iodine: (2-3 times daily). 
  • Melatonin: (5-10 mg at night — slow-release formulation preferred). 
  • Nigella sativa: (seeds 80 mg/kg once a day or encapsulated oil 400-500 mg twice a day) taken with honey (1 g/kg one to two times a day). 
  • Aspirin: 325 mg daily unless contraindicated). 
  • Home pulse oximetry High-risk patients (aged over 60, comorbidities, poorly ambulatory), delayed treatment, high D-dimer, recently vaccinated, or severe symptoms, should add: 
  • Apixaban: (5 mg daily for 15 days) OR Rivaroxaban (10 mg daily for 15 days). 
  • Spironolactone: (200 mg once daily for 7 days — avoid in patients with impaired renal function). If symptoms have not markedly improved by day 3 of treatment, the following medications should be started. [NOTE: physicians should provide prescriptions for these medications at first visit.]
  • Prednisolone: (60 mg daily for 5 days).
  • Oral antibiotic: Doxycycline (100 mg twice daily for 5 days) (Doxycycline may act synergistically with ivermectin and may be the antibiotic of first choice) OR Azithromycin (Z-pack) (500 mg day 1, then 250 mg daily for 4 days) OR Amoxicillin/ Clavulanate (Augmentin) (500 mg/125 mg tablet twice daily for 7 days). 



About FLCCC Alliance

The Front Line COVID-19 Critical Care (FLCCC) Alliance was initially formed as a working group under “emergency” conditions of the early COVID-19 pandemic in response to multiple early reports of COVID patients with an inexplicably high need for prolonged mechanical ventilation and an excessive mortality associated with the prevailing “supportive care only” recommendations disseminated by the majority of national and international health care organizations.

As a group of highly published leaders in critical care with expertise in therapies directed at severe infections, in particular “HAT” therapy first developed by Dr. Paul Marik for the treatment of bacterial sepsis, and along with published high patient survival rates from our centers, we were contacted by equally concerned and motivated colleagues from other specialties.

In October 2020, the FLCCC Alliance identified, based on a review of the recent and rapidly emerging clinical trials evidence, that ivermectin, an anti-parasitic medicine, has highly potent real-world, anti-viral, and anti-inflammatory properties against SARS-CoV-2 and COVID-19. This conclusion is based not only from multiple in-vitro and animal models, but from numerous clinical trials from centers and countries around the world showing repeated, consistent, large magnitude improvements in clinical outcomes when ivermectin is used not only as a prophylactic agent but also in mild, moderate, and even severe disease states. Further, data from large “natural experiments” that appear to have occurred when various regional health ministries and governmental authorities within South American countries initiated “ivermectin distribution” campaigns which then led to temporally associated decreases in case counts and case fatality rates.

Related:

Disclaimer: Always see your doctor before taking these supplements. Be aware that most of the 'treatment' dosages are above the recommended dietary allowance (RDA) and therefore such dosages should not be maintained on a long term basis. 

Our aim here isn't to replace your doctors' advice. It is intended as a sharing of knowledge and information. Do take note that supplements are not 100% protective or curative against COVID-19. 

Nutritional supplements are meant to tip the scales in favour of you in terms of your immune system and to improve your probability of a smooth recovery, if at all you do get COVID-19. 

You still need to follow the advice given by CDC, WHO and your local authority in terms of local guidelines such as mask wearing, social distancing, vaccination and avoiding crowds. It's better to combine multiple strategies in order to defend yourself against this virus.

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