Front Line Doctors Ivermectin Protocol for Prevention and Treatment of COVID-19 (May 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 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 protocol.

McCullough et al. Reviews in Cardiovascular Medicine, 2020


FLCCC (Front Line COVID-19 Critical Care) Protocols

FLCCC Putting Patients First

The initial MATH+ protocol was released in April 2020. In early July and August, it was updated to include quercetin and a number of optional nutrients and drugs, not only for critical care but also for prophylaxis and mild disease being treated at home.

There is evidence that vitamin C and quercetin co-administration exerts a synergistic antiviral action due to overlapping antiviral and immunomodulatory properties and the capacity of ascorbate to recycle quercetin, increasing its efficacy.

The I-MASK+ protocol has been updated several times and below is their latest version (version 19: Jan 19, 2022).

PREVENTION PROTOCOL (for Delta variant)

Should I take ivermectin as a prophylaxis? For preventive measures, the Front Line COVID-19 Critical Care Working Group (FLCCC) I-MASK+ protocol recommends:

Anti-Virals & AntiSeptics
  • Gargle mouthwash: 2 x daily – gargle (do not swallow) antiseptic mouthwash with cetylpyridinium chloride (e.g. Crest mouthwashScope mouthwash™, Act, Colgate mouthwash) or povidone iodine 1 % solution as alternative (e.g. Betadine® Antiseptic Sore Throat Gargle™). 
  • lvermectin
    • Chronic Prevention: 0.2 mg/kg per dose (take with or after a meal) — twice a week for as long as disease risk is elevated in your community (Ref). Alternative: Hydroxychloroquine – 200 mg tablet daily.
    • Post COVID-19 Exposure Prevention: 0.4 mg/kg per dose (take with or after a meal)  — one dose today, repeat after 48 hours. Alternative: Hydroxychloroquine – 400mg twice day on day 1, then 200mg twice a day on Days 2 and 3.
Related: 
Immune Fortifying / Supportive Therapy
  • Vitamin D3: Optimal approach to dosing requires testing of 25(OH)D level. For dosing guidance, see Table 1 if level is known and Table 2 if level is unknown (below) (Amazon
  • Vitamin C: 500 - 1,000 mg BID (twice daily) (Amazon
  • Quercetin: 250 mg daily.  (Amazon
  • Zinc: 30 - 40 mg/day (elemental zinc). Zinc lozenges are preferred. (Amazon
  • Melatonin: 6 mg before bedtime (causes drowsiness). (Amazon)
Ivermectin Alternative
To be used if ivermectin not available or added to ivermectin for optimal prevention.

Notes:
  • High risk Individuals: > 60 years with co-morbidities (hypertension, diabetes, chronic lung disease, chronic kidney disease), obesity, long term care facilities, etc.
  • Post COVID-19 exposure: To use if a household member is COVID-19 positive, or you have prolonged exposure to a COVID-19 positive patient without wearing a mask.
  • Precautionary Note: Ivermectin has a number of potentially serious drug-drug interactions. Please check for potential drug interaction at Ivermectin Drug Interactions - Drugs.com. The most important drug interactions occur with cyclosporin, tacrolimus, anti-retroviral drugs, and certain anti-fungal drugs. 
  • Due to the possible drug interaction between quercetin and ivermectin (may increase ivermectin levels), these drugs should not be taken simultaneously (i.e. should be staggered morning and night). 
  • Ivermectin is also lipophilic and therefore, bioavailability is maximised on a full stomach; or best to be taken with meal.
  • Vitamin D3 RDA (Recommended Daily Allowance) is 800–1000 IU/day. The safe upper-dose daily limit is likely < 4000 IU/day. Vitamin D deficiency has been associated with an increased risk of acquiring COVID-19 and from dying from the disease. Vitamin D supplementation may therefore prove to be an effective and cheap intervention to lessen the impact of this disease, particularly in vulnerable populations, i.e. the elderly and obese.
  • When Is the Best Time to Take Vitamin D? Morning or Night? It is possible that increasing vitamin D levels during the day may act, in part, as a signal that suppresses melatonin generation (source). Therefore, it's better to take vitamin D (with meal) during the day and melatonin to be taken just before bedtime.
  • It is likely that vitamin C and quercetin have synergistic prophylactic benefit. Quercetin should be used with caution in patients with hypothyroidism and TSH levels should be monitored.
  • Please consult with a qualified doctor and only use human ivermectin. Ivermectin for animals contain excipients (binding and storage compounds such as polyethylene glycol (PEG)) that are known to cause liver failure in high doses. 
  • There have been reports of visual problems associated with ivermectin. However, the effect is minor and transient.
Related: 

EARLY TREATMENT PROTOCOL

For early outpatient protocol (COVID-19 positive), the Front Line COVID-19 Critical Care Working Group, FLCCC I-MASK+ protocol recommends:

1. First line agents (use any or all medicines; listed in order of priority/importance)

Anti-Virals
  • Ivermectin: 0.4–0.6 mg/kg per dose (take with or after meals) — one dose daily, take for 5 days or until recovered. (Find a Doctor). Use upper dose range if:  1) in regions with more aggressive variants (e.g. Delta); 2) treatment started on or after day 5 of symptoms or in pulmonary phase; or 3) multiple comorbidities/risk factors. (Ref)
  • Hydroxychloroquine (preferred for Omicron): 200mg PO twice daily; take for 5 days or until recovered. (Find a Doctor)
Anti-Septic Anti-virals
  • Antiviral mouthwash: Gargle 3 x daily (do not swallow; must contain chlorhexidine,  povidone-iodine, or cetylpyridinium chloride). (e.g. Crest mouthwashScope mouthwash™,  Colgate mouthwashBetadine® Antiseptic Sore Throat Gargle)
  • Iodine Nasal Spray/Drops: Use 1 % povidone iodine commercial product as per instructions 2–3 x daily. If 1 %-product not available, must first dilute the more widely available 10 %-solution and apply 4–5 drops to each nose every 4 hours. (No more than 5 days in pregnancy)
Anti-Coagulants + Immune Fortifying
  • Aspirin: 325 mg/day unless contraindicated. (Amazon)
  • Vitamin D3: Optimal approach to dosing requires testing of 25(OH)D level. For dosing guidance, see Table 1 if level is known and Table 2 if level is unknown (above) (Amazon
  • Melatonin: 10 mg before bedtime (causes drowsiness). (Amazon)
Synergistic Therapies
  • Vitamin C: 500 - 1,000 mg BID (twice daily) (Amazon)
  • Quercetin: 250 mg twice a day. (Amazon)
  • Zinc: 100 mg/day. Zinc lozenges are preferred. (Amazon)
Nutritional Therapeutics (New)
  • Curcumin (turmeric) 500mg 2 x daily for 14 days (Ref) (Amazon)
  • Nigella Sativa (Black Seed) 80mg/kg daily for 14 days (Amazon)
  • Honey 1gram/kg daily for 14 days
Pulse Oximeter

FLCCC also recommend monitoring your oxygen saturation with a pulse oximeter and to go to the hospital if you get below 94%. (Amazon)

Other Alternatives: 
* Not available on Amazon

2. Second line agents (listed in order of priority /importance)

Add to first line therapies above if: 
1) ≥5 days of symptoms; 
2) Poor response to therapies above; 
3) Significant comorbidities

Dual anti-androgen Therapy
  1. Spironolactone 100 mg 2 x daily for ten days
  2. Dutasteride 2 mg on day 1, followed by 1 mg daily for 10 days. If dutasteride is not available, use finasteride 10 mg daily for 10 days.
Note: Dutasteride and finasteride are contraindicated in pregnancy.

Fluvoxamine

Fluvoxamine: 50 mg twice daily for 10 days. 
Consider fluoxetine (Prozac) 30mg daily for 10 days as an alternative (it is often better tolerated).
Avoid if patient is already on an SSRI.

Notes: 
  • Combining fluvoxamine and melatonin may significantly increase the blood levels and effects of melatonin (Drugs.com). You can check for other potential drug interactions with fluvoxamine at Fluvoxamine Drug Interactions - Drugs.com.
  • 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.
Monoclonal antibody therapy

Sotrovimab: 500mg each in a single intravenous infusion. Antibody therapy is for patients within 5 days of first symptoms, non-severe symptoms, and one or more risk factors as: 
  • Age>55y; 
  • BMI>25; 
  • pregnancy; 
  • chronic lung, heart, or kidney disease; 
  • diabetes. 
Trials data supporting sotrovimab against Omicron are not available, however the manufacturer has claimed it retains neutralizing capability against this variant.

3. Third line agent 

To consider if after day 7–10 from first symptoms and patient has either: abnormal chest x-ray, shortness of breath, or oxygen saturations of 88–94%. If oxygen saturation is lower than 88%, emergency room evaluation should be sought.

Prednisone or Methylprednisolone: 1mg/kg daily for 5 days followed by slow taper or escalation according to patient response. 

Behavioral Prevention

  • Face Masks - Must wear cloth, surgical, or N95 mask (without valve) in all indoor spaces with non-household persons. Must wear a N95 mask (without valve) during prolonged exposure to non-household persons in any confined, poorly ventilated area.
  • Social Distancing - Until the end of the COVID-19 crisis, we recommend keeping a minimum distance of approx. 2 m / 6 feet in public from people who are not from your own household.
  • Wash Hands - We recommend, after a stay during and after outings from home (shopping, sub - way etc.), a thorough hand cleaning (20–30 sec. with soap), or also to use a hand disinfectant in between.
The medical evidence to support each drug and nutrient can be found under “Medical Evidence” on the FLCCC’s website.

For an up-to-date overview of all published studies on ivermectin in the treatment and prevention of COVID-19 we recommend visiting c19ivermectin.com; in addition, a meta-analysis of all studies can be found at ivmeta.com (constantly updated). For adoption and regulatory status of ivermectin globally, check out "Countries using Ivermectin".

For post-COVID or long COVID syndrome, check out Long Haulers Treatment Protocol


Alternatives: 
* Not available on Amazon

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.


With the increasing publications in addition to our rapidly accumulating personal clinical experiences and investigations into the pathophysiology of COVID-19 patients, we formulated the MATH+ Hospital Treatment Protocol in March 2020. On August 5, 2020, we published our findings in the rationale paper Scientific Review of COVID-19 and MATH+.

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.

Based on these findings, the FLCCC team has developed the I-MASK+ protocol for prophylaxis and at home treatment of early stage disease.

Related:


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Z-Stack Supplement (Advertorial)

In an effort to make it easier for patients, Dr Zelenko has developed an oral supplement that contains all four key ingredients: vitamin C, quercetin, vitamin D3 and zinc. It’s referred to as 'Z-Stack Supplement'. 
Z STACK Zelenko
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The cost of the Z-STACK vitamin cocktail is $55 per bottle for a one month supply. 

Where to buy Z-Stack: Z-stack is available on Dr Zelenko's website. Here is the link: Z Stack Supplement 

Note: To get 5% OFF, please use this coupon code: DRFRANCIS

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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