Long Hauler Syndrome: Symptoms and Treatment Protocol (September 2022)

By Dr Frank Yap, M.D. - February 27, 2023

In this article, we will discuss what long hauler syndrome is. You will learn about the major signs and symptoms of long-hauler syndrome.

We will also talk about diagnosis and conventional treatment options for long-hauler syndrome. We will share our top natural support strategies for long-hauler syndrome, including some key supplements.

What is Long Hauler Syndrome?

Long hauler syndrome is a condition characterized by various chronic symptoms after a COVID-19 infection. These long-term symptoms may last for weeks, months, or even a year after recovering from the initial COVID-19 illness. Unfortunately, long hauler syndrome is quite common.

As of Sept. 26, 2022, federal data published by the US CDC found that 15% of adults who previously had a COVID-19 infection are currently experiencing symptoms of long COVID.

Of those adults with long COVID, 81% report that their long-term symptoms from the condition have reduced their ability to carry out day-to-day activities. A quarter of the adults with long COVID said that the limitations were “significant.”

The highest rate of daily activity limitations come from the 18-29 age group, while the lowest rate comes from the 40-49 age group.

The survey’s results mean that over 18 million adult Americans are currently experiencing symptoms of long COVID and 15 million have problems performing daily activities because of it.

The data helps to round out the picture of long COVID, a condition the CDC defines as a “wide range of new, returning or ongoing health problems people can experience four or more weeks after first being infected with the virus that causes COVID-19.”

The federal numbers mostly align with estimates from the Brookings Institution that 16 million working age Americans – aged 18 to 65 – are currently experiencing long COVID.

The Brookings report also looked at how long COVID is affecting American lives, finding that up to 4 million working-age adults are out of a job due to long COVID.

Long COVID risk less from omicron variant than from delta

The omicron variant is less likely to cause long COVID than the delta variant, new research has found. Analysis by researchers from King's College London of data from the ZOE COVID Symptom study app is published in The Lancet (June 2022). The findings are from the first peer-reviewed study to report on long COVID risk and the omicron variant.

Long COVID is defined by NICE guidelines as producing new or ongoing symptoms four weeks or more after the start of disease. Symptoms include fatigue, shortness of breath, loss of concentration and joint pain. The symptoms can adversely affect day-to-day activities, and in some cases can be severely limiting. Researchers found the odds of experiencing long COVID were between 20-50% less during the omicron period versus the delta period, depending on age and time since vaccination.

The UK Office of National Statistics estimated the numbers of people with long COVID actually increased from 1.3 million in January 2022 to 2 million as of May 1, 2022.

Lead author, Dr. Claire Steves from King's College London, said, "The omicron variant appears substantially less likely to cause long COVID than previous variants, but still 1 in 23 people who catch COVID-19 go on to have symptoms for more than four weeks.

Long Haulers Symptoms

Clinical signs and symptoms can be grouped in the following clusters. The reason for this grouping is to allow organ specific targeted therapy/individualized therapy:

1. Respiratory (Lung): shortness of breath, congestion, persistent cough, etc.

2. Neurological/psychiatric: brain fog, malaise, tiredness, headaches, migraines, depression, inability to focus/concentrate, altered cognition, insomnia, vertigo, panic attacks, tinnitus, anosmia, parosmia, phantom smells, etc.

3. Musculoskeletal: myalgias, fatigue, weakness, joint pains, inability to exercise, post-exertional malaise, inability to perform normal activities of daily life (ADL’s).

4. Cardiovascular: Palpitations, arrhythmias, Raynaud like syndrome, hypotension, and tachycardia on exertion.

5. Autonomic Nervous System: Postural tachycardia syndrome (POTs), abnormal sweating.

6. Gastro-Intestinal disturbance: Anorexia, diarrhea, bloating, vomiting, nausea, etc.

7. Dermatologic (Skin): Itching, rashes, dermatographia

8. Mucus membranes: Running nose, sneezing, Burning and itchy eyes.

9. Auditory (Ear): tinnitus, hearing loss and vertigo. (International Journal of Audiology, Nature)

Note: 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.

COVID-19 long haulers report that these symptoms flare up unpredictably. They are often in different combinations and can be debilitating for days and weeks at a time.

In one Italian study, COVID-19 long-haulers experienced fatigue, shortness of breath, joint pain, and chest pain, in that order. None of the patients in that study had a fever after their acute illness had passed. However nearly half of them reported their quality of life had suffered.

Although numerous reports describe the epidemiology and clinical features of post-COVID syndrome, studies evaluating treatment options are glaringly sparse. Indeed, the NICE guideline for managing the long-term effects of COVID-19 provide no specific treatment recommendations. In general, while the treatment of ‘Long COVID” should be individualized, the following supplements may have a role in the treatment of this disorder.

Natural Key Supplements for Long Haulers

Nutraceutical Therapy by Mode of Action

1. N-Acetyl-L-Cysteine (NAC)

NAC is an amino acid that the body uses to create glutathione, the body’s master detoxifier. Glutathione is your master detoxifier and the most powerful free radical scavenger produced by your body.

Eating plenty of cruciferous vegetables (such as kale, broccoli, and cabbage), as well as avocado, okra, spinach, and alliums, can help bolster levels of glutathione, as can supplementing with NAC.

A 2017 paper found NAC has potent thrombolytic effects, meaning it breaks down blood clots once they've formed.

Importantly, NAC may also protect against other problems associated with COVID-19, including the hypercoagulation that can result in stroke and/or blood clots that impair the ability to exchange oxygen in the lungs.

Many COVID-19 patients experience serious blood clots, and NAC counteracts hypercoagulation, as it has both anticoagulant and platelet-inhibiting properties.

Aaron Hartman, MD, founder of the Richmond Integrative and Functional Medicine clinic in Richmond, Va., describes one patient, a 26-year-old woman, whose symptoms — persistent low oxygen and shortness of breath — following a bout of COVID resolved after treatment that included NAC as well as omega-3 fish oil.

“NAC is one of the more important nutrients for people who get shortness of breath with COVID, because of its ability to break down those really, really small blood clots called micro-emboli,” explains Hartman.

2. Vitamin D

Vitamin D3 is essential for supporting healthy immune system function. It works hand in hand with your body to modulate both innate and adaptive immune responses which regulate everything from reactivity to antigens and pathogens.

Maintaining good vitamin D status should be a priority even as a preventative, and may help restrain inflammation from elevating during COVID in the first place.

Much has been written about the emerging link between COVID severity and vitamin-D deficiency. A pilot study in Spain found that adding oral D3 supplementation significantly reduced the need for ICU treatment among people hospitalized after infection.

Vitamin D is also part of the FLCCC i-Recover protocol (below).

Leo Galland, MD, a functional-medicine internist in New York City notes that D is an important promoter of ACE-2 activity. He recommends that people with long COVID supplement with up to 5,000 IU of D3 daily. Hartman advises aiming for a vitamin-D blood level in the range of 60 to 80 ng/mL.

3. Resveratrol

Resveratrol is a polyphenol with antioxidant and anti-inflammatory effects that’s found in red grapes, red wine, peanuts, and some berries. It’s also available as a supplement.

Leo Galland, MD, a functional-medicine internist in New York City, has found it to be particularly helpful in restoring his COVID patients to health. “Resveratrol has a number of beneficial effects on coronavirus infection,” he notes. “It supports ACE-2 function, it inhibits the growth of the deadly MERS coronavirus through multiple mechanisms, and it diminishes the kind of inflammation associated with coronavirus infection.”

Galland treated a physician in her 60s who’d been sick with COVID for six weeks, continuing to run daily fevers with brain fog and fatigue. He prescribed a combination of herbs and supplements, including resveratrol, and her symptoms resolved within a couple of weeks.

He recommends long-COVID patients supplement with 200 mg of resveratrol twice a day.

4. Probiotics

COVID can wreak havoc on the gut microbiome, but research on specific probiotic strains that can best restore balance following the syndrome’s particular damage is in its infancy. Leo Galland, MD, a functional-medicine internist in New York City, is looking into soil-derived bacteria of the genus Bacillus because it may have natural antibiotic properties, though there’s not yet enough data to make specific recommendations.

One Swedish study demonstrated that taking probiotics for 14 days could help alleviate some of the symptoms of long COVID, namely muscle soreness and brain fog. We also recommend optimizing your gut microbiome by avoiding processed vegetable oils, processed foods and conventionally raised meats in animal products.

Eating fermented foods, such as sauerkraut, yogurt, kefir, and kimchi, can help fortify and support the gut’s microbiome. And in the event of ongoing gut disturbances, working with a functional-medicine provider to design a well-rounded prebiotic and probiotic protocol can help bring the microbiome back into balance.

As reported in this short news clip, research evidence shows that probiotics may help reduce long-haul symptoms after COVID-19. Some people experience symptoms for weeks or months after a COVID-19 infection has resolved. When these symptoms persist for four weeks or more, they are known as long COVID, long-haul COVID, chronic COVID or long-haul syndrome.

5. Melatonin

Melatonin is an anti-inflammatory and antioxidant chemical our bodies produce to help regulate the sleep–wake cycle. It also supports the gut lining, which promotes healthy immune function.

Supplementing with 1 - 2 mg of melatonin at bedtime might benefit those whose sleep–wake cycles have become dysregulated with long COVID.

6. Omega-3 fatty acids

Vascepa, Lovaza or DHA/EPA 4 g day. Omega-3 fatty acids play an important role in the resolution of inflammation by inducing resolvin production. [Ref, Ref]

Evidence: Two peer-reviewed randomized, controlled trials suggest that omega-3 fatty acids help hasten recovery from COVID, and when given to ICU patients may make them six times more likely to survive.

Omega-3 is also part of the FLCCC i-Recover protocol (below).

7. Vitamin C

Vitamin C inhibits histamine. Healthcare professionals are administering vitamin C intravenously to deliver it directly into their patient’s bloodstream to be immediately available. Liposomal vitamin C is the next best option. It’s the most bioavailable form of vitamin C on the market today. The liposomal form can survive the digestive process to be up to 135% better than traditional oral vitamin C.

Long-COVID patients can supplement with vitamin C 500 mg twice a day.

Related: Best Vitamin C Supplement

8. Quercetin, EGCG and Curcumin

Quercetin has broad spectrum anti-inflammatory properties. These natural flavonoids inhibit mast cells and have been demonstrated to reduce neuro-inflammation.

Quercetin is a flavonoid found in dill, broccoli, onions, capers, apples, and berries. Quercetin is a mast-cell stabilizer and has been used with people who have allergies, asthma, and mast-cell issues.

Quercetin appears to bind to the spike protein of the coronavirus, inhibit inflammatory pathways, and block replication of infected cells. It is also antiviral and completely safe. In addition to getting sources of quercetin from diet, long-COVID patients can supplement with 250 - 500 mg twice a day.

Other phytonutrients such as EGCG (epigallocatechin gallate, a polyphenol found in green tea) and curcumin (found in turmeric) can decrease inflammation and rebalance the immune system.

9. Zinc

Zinc is essential for healthy immune function. A 2020 review published in the International Journal of Infectious Diseases has found that zinc deficiency can increase the risk of poor outcomes in viral infections, including COVID-19.

Foods that are rich in zinc include meat, poultry, shellfish, eggs, dairy, seeds, nuts, legumes, sweet potatoes, quinoa, and green leafy vegetables.

10. Lumbrokinase and Serrapeptase

If you’ve had COVID-19, especially if it was a severe case, be aware that blood clots and heart problems, including heart attack, can occur for 90 days or more. It’s believed that remnants of the virus remain in the nervous system, the lungs, the heart and other organs.

If the symptoms include major shortness of breath, cough with blood in it or pain on one side when you take a deep breath, it could be due to a late pulmonary embolism or a blood clot going to the lungs.

A safer and likely equally effective alternative to aspirin is digestive fibrinolytic enzymes like lumbrokinase and serrapeptase. You can alternate between the two enzymes — one day take lumbrokinase and the next take serrapeptase — because you’ll need to be on it for about three months and you can develop a sensitivity to them over time.

Anyone who had COVID-19, especially with significant symptoms, should consider taking digestive fibrinolytic enzymes to be sure you don’t have any clotting. An alternative to determine if clotting is occurring is a test called D-dimer, although it can be pricey. D-dimer is a protein fragment produced by the body when a blood clot dissolves.

It’s typically undetectable or present only at very low levels, buts its level may significantly rise when the body is forming and breaking down blood clots (R). If your d-dimer test is low, then you don’t need to take the enzymes. Likewise, if you had a very mild, cold-like case, of COVID-19, you probably don’t need them.

Anti-Inflammatory Nutrition Plan

Immune dysfunction, inflammation, and oxidative stress may all play a role in post-viral syndrome. An anti-inflammatory nutrition plan may help to improve your immune health and reduce inflammation and oxidative stress. According to a 2021 review published in Clinical Nutrition ESPEN, an anti-inflammatory diet may help with viral respiratory infections. A 2020 review published in Frontiers in Immunology has found that an antioxidant-rich, anti-inflammatory nutrition may support the immune system and help with COVID-19-related pathogenesis.

Follow on anti-inflammatory, nutrient-dense whole foods, such as greens, vegetables, sprouts, herbs, spices, fermented food, grass-fed beef, pasture-raised poultry and eggs, wild-caught fish, and wild game. Eat lots of healthy fats, such as coconut oil, grass-fed butter and ghee, avocados, olives, and extra-virgin olive oil.

Add anti-inflammatory spices, such as turmeric, ginger, onion, garlic, oregano, basil, rosemary, and cinnamon.

Original Image: DrJockers.com

Long Haulers Syndrome Treatment Protocol: FLCCC I-Recover Protocol

Given the lack of clinical trials of long-haul COVID-19 syndrome, these recommendations are based on the abnormal changes within the body associated with the COVID-19 disease and post viral illnesses along with the collective experience of FLCCC members.

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.

The I-Recover protocol has been updated and below is their latest version (version 2: Jan 20, 2022).

First-line treatments based on the FLCCC I-Recover Protocol.
Ivermectin: 0.2mg/kg body weight. Once daily for 1 week. Discontinue after 2 - 4 weeks if all symptoms have resolved. A repeat course is recommended in those who respond poorly or relapse once the treatment is stopped. The anti-inflammatory properties of ivermectin may mediate this benefit. (Find a Doctor)
Prednisone: 10–15mg daily for 3 weeks. Taper to 10mg for three days, then 5mg for three days and then stop.
Low dose naltrexone (LDN): Begin with 1 mg daily and increase to 4.5mg as required. May take 2–3 months for full effect.
Omega-3 fatty acids: Vascepa, Lovaza or DHA/EPA 4g per day. Omega-3 fatty acids play an important role in the resolution of inflammation by inducing resolvin production. [Ref, Ref]
If symptoms do not improve after 1–2 weeks continue steroids, omega-3 fatty acids and Naltrexone and add second line medications.
Vitamin D: The majority of those with post-COVID-19 syndrome continue to have hypovitaminosis D. See tables 1 or 2 for vitamin D supplementation.

2nd Line Therapies
Fluvoxamine (low dose): 25mg once daily. Stop if the symptoms increase. Caution with the use of other antidepressants and psychiatric drugs. Taper and discontinue once symptoms improve.
Atorvastatin: 20–40mg once daily. Caution in patients with Postural Orthostatic Tachycardia Syndrome (POTS); may exacerbate symptoms.
3rd Line Therapy
Maraviroc: 300mg PO twice a day If 6–8 weeks have elapsed and significant symptoms persist, consider either getting an InCellDx test to assess long hauler index profile prior to initiating or can consider initiating empirically. Note maraviroc can be expensive and it has risk for significant side effects and drug interactions.
4. Optional adjunctive therapies (in order of priority)
Curcumin: has anti-inflammatory and immunomodulating properties and has been demonstrated to repolarize macrophages.
Nigella Sativa: which like curcumin has anti-inflammatory and immunomodulating properties.
Vitamin C: 500mg BID (vitamin C inhibits histamine and repolarizes monocytes). [Ref]
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.
Behavioral modification, mindfulness therapy and psychological support may help improve survivors’ overall well-being and mental health.
Luteolin 100–200mg day or Quercetin 250mg day (or mixed flavonoids). Luteolin and quercetin have broad spectrum anti-inflammatory 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.
H2 receptor blockers (for mast cell activation syndrome): Famotidine 20–40mg, or Nizatidine 150mg — twice daily as tolerated.
Montelukast: 10mg/day (for mast cell activation syndrome). Caution as may cause depression in some patients.
Anti-androgen therapy: Spironolactone 50–100mg twice a day, and Dutasteride 1mg daily.
Mast cell stabilisers: rupadatadine, quercetin or luteolin.

Editor's Notes:
Low dose aspirin (75 mg) for two weeks post vaccination to reduce risk of clotting (patrickholford.com, drmalcolmkendrick.org).
On 26 May 2021, the COVID-19 subcommittee of the WHO Global Advisory Committee on Vaccine Safety (GACVS) issued a statement reviewing initial reports of mild myocarditis following COVID-19 mRNA vaccines. They also pointed out that "available data suggest that the immediate course of myocarditis and pericarditis following vaccination is generally mild and responds to conservative treatment (e.g. rest, treatment with non-steroidal anti-inflammatory drugs etc)."

Post-Vaccination Long Haulers?

The I-Recover Post Vaccine Treatment Protocol version 3 (July 13, 2022) has been launched by FLCCC. Do not get confused with the I-Recover protocol for long haulers that was mentioned above.

For post-vaccinated risk of heart complications, there are a few basic strategies as advised by Dr Mercola:

Make certain you measure your blood vitamin D level and take enough vitamin D orally (typically about 8,000 units/day for most adults) to make sure your level is 60 to 80 ng/ml (100 to 150 nmol/l).
Eliminate all vegetable (seed) oils in your diet, which involves eliminating nearly all processed foods and most meals in restaurants unless you convince the chef to only cook with butter. Avoid any sauces or salad dressings in restaurants as they are loaded with seed oils. Also avoid chicken and pork as they are very high in linoleic acid, the omega-6 fat that is far too high in nearly everyone and contributes to oxidative stress that causes heart disease.
Consider taking around 500 mg/day of NAC, as it helps prevent blood clots and is a precursor for your body to produce the important antioxidant glutathione.
Consider fibrinolytic enzymes that digest the fibrin that leads to blood clots, strokes and pulmonary embolisms. The dose is typically two, twice a day, but must be taken on an empty stomach, either an hour before or two hours after a meal. Otherwise, the enzymes will digest your food and not the fibrin in the blood clot.

Find health care providers: FIND A DOCTOR WHO WILL PRESCRIBE IVERMECTIN, HYDROXYCHLOROQUINE AND EARLY OUTPATIENT TREATMENTS FOR COVID-19 (USA)

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Ingredients:

Epigallocatechin gallate (EGCG) is an extract of green tea and is a powerful zinc Ionophore (zinc delivery system).
N-acetyl cysteine (NAC) is a supplement form of cysteine. It may prevent blood clots and is an antioxidant.
Zinc is critical for immune cell development. Dozens of different enzymes in the body rely on zinc.
Vitamin C is an essential nutrient involved in the repair of tissue and the enzymatic production of certain neurotransmitters.
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Bruce Patterson Long Hauler Protocol

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