Exhibit (complaint, Ex. 8) — Apter v. HHS

Record facts

U.S. District Court for the Southern District of Texas (Galveston Division) · No. 3:22-cv-00184 · Doc. 1-8 · 2022-06-02 · Docket on CourtListener

Full text

Exhibit 8
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Page 1 of 40 | EVMS – COVID-19 Management Protocol 2020-12-17 
EVMS COVID-19 MANAGEMENT PROTOCOL 
Developed and Updated by Paul Marik, MD, FCP (SA), FRCP (C), FCCP, FCCM. 
Professor of Medicine, Chief of Pulmonary and Critical Care Medicine 
Eastern Virginia Medical School 
December 17th, 2020 
This is our recommended approach to COVID-19 based on the best (and most recent) literature. This is a 
highly dynamic topic; therefore, we will be updating the guideline as new information emerges. 
EVMS COVID website: https://www.evms.edu/covid-19/medical_information_resources/ 
Short url:  evms.edu/covidcare 
Disclaimer: The information in this document is provided as guidance to physicians World-Wide 
on the prevention and treatment of COVID-19.  Our guidance should only be used by medical 
professionals in formulating their approach to COVID-19.  Patients should always consult with 
their physician before starting any medical treatment. 
An overview of the MATH+ and I-MASK+ Protocols 
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Figure 1.  The course of COVID-19 and General Approach to treatment 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
THIS IS A STEROID RESPONSIVE DISEASE: 
HOWEVER, TIMING IS CRITICAL 
 
 
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Table 1. Pharmacological therapy for COVID by stage of illness: What has worked and what 
has failed* 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*based on randomized controlled trials (see supporting information below) 
 
 
 
 
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Figure 2.  Timing of the initiation of anti-inflammatory therapy 
 
 
 
 
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Figure 3. Time course of laboratory tests for COVID-19 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 4.  SARS-Co-V-2 RNA genome 
 
 
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It should be noted that there is no cure or “Magic-bullet” for the prevention or treatment of COVID-19. 
However, recently, a number of therapeutic agents have shown promise for both the prevention and 
treatment of COVID-19 including ivermectin, Vitamin D, quercetin, melatonin and corticosteroids. 
Furthermore, it is likely that no single drug will be effective in treating this complex disease and that 
multiple drugs with different mechanisms of action and used in specific phases of the disease will be 
required. 
 
Prophylaxis 
While there is no “Level 1 evidence” that this “cocktail” will prevent/mitigate against COVID-19 we 
believe there is significant evidence supporting the efficacy of the individual agents included in the 
prophylactic protocol. This protocol MUST be part of an overall strategy which includes common sense 
public health measures, i.e. masks, social distancing, and avoidance of large groups of people. 
Furthermore, it should be noted that there is emerging evidence suggesting that IVERMECTIN may be 
highly effective in the prevention and treatment of COVID-19. It is important to emphasize that ALL of 
the medications included in our prophylactic regimen are inexpensive, safe, and widely available.  
• 
Vitamin D3 1000–3000 IU/day. Note RDA (Recommended Daily Allowance) is 800–1000 IU/day. 
The safe upper-dose daily limit is likely < 4000 IU/day. [1-22] Vitamin D insufficiency 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, those of 
color, obese and those living > 45o latitude. [7-22] 
• 
Vitamin C 500 mg BID (twice daily) and Quercetin 250 mg daily. [23-34] It is likely that vitamin C 
and quercetin have synergistic prophylactic benefit. [35] It should be noted that in vitro studies 
have demonstrated that quercetin and other flavonoids interfere with thyroid hormone 
synthesis at multiple steps in the synthetic pathway. [36-39] The use of quercetin has rarely 
been associated with hypothyroidism. The clinical impact of this association may be limited to 
those individuals with pre-existent thyroid disease or those with sub-clinical thyroidism.[40] In 
women high consumption of soya was associated with elevated TSH concentrations.[41] The 
effect on thyroid function may be dose dependent, hence for chronic prophylactic use we 
suggest that the lowest dose be taken. Quercetin should be used with caution in patients with 
hypothyroidism and TSH levels should be monitored. It should also be noted quercetin may have 
important drug-drug interactions; the most important drug-drug interaction is with cyclosporin 
and tacrolimus. [42] In patients taking these drugs it is best to avoid quercetin; if quercetin is 
taken cyclosporin and tacrolimus levels must be closely monitored.  
• 
Melatonin (slow release):  Begin with 0.3 mg and increase as tolerated to 2 mg at night. [43-50] 
• 
Zinc 30–50 mg/day (elemental zinc). [23,30,32,33,51-55] 
• 
B complex vitamins [56-60] 
• 
Ivermectin for postexposure prophylaxis (see ClinTrials.gov NCT04422561).  0.2 mg/kg (12 mg) 
immediately then repeat day 3.   
• 
Ivermectin for pre-exposure prophylaxis (in HCW) and for prophylaxis in high-risk individuals 
(> 60 years with co-morbidities, morbid obesity, long term care facilities, etc). 0.15–0.2 mg/kg 
Day 1, Day 3 and then weekly for 10 weeks, followed by biweekly dosing. [5,61-64] (also see 
ClinTrials.gov NCT04425850). See dosing Table below. NB. 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.  
 
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• Optional: Famotidine 20–40 mg/day [55–61].  Low level evidence suggests that 
famotidine may reduce disease severity and mortality. However, the findings of some 
studies are contradictory. While it was postulated that famotidine inhibits the SARS-
CoV-2 papain-like protease (PLpro) as well as the main protease (3CLpro) this 
mechanism has been disputed.[58] Furthermore, a single study suggested that users of 
PPI’s had a significantly increased odds for reporting a positive COVID-19 test when 
compared with those not taking PPIs, while individuals taking histamine-2 receptor 
antagonists were not at elevated risk.[62] This data suggest that famotidine may be the 
drug of choice when acid suppressive therapy is required.  
• 
Optional/Experimental: Interferon-α nasal spray for health care workers [54] 
 
Ivermectin dosing:  150-200 ug/kg  or fixed dose of 12 mg (≤ 80kg)  or 18 mg (≥ 80kg).[65] Depending on 
the manufacturer ivermectin is supplied as 3mg, 6 mg or 12 mg tablets.  
50-64.9 kg   - 12mg 
65-79.9 kg   - 15mg 
80-94.9 kg   - 18mg 
95-109.9 kg - 21mg 
≥ 110 kg       - 24mg  
 
Symptomatic patients at home (for the duration of acute symptoms) 
• 
Vitamin C 500 mg BID and Quercetin 250–500 mg BID  
• 
Zinc 75–100 mg/day (elemental zinc) 
• 
Melatonin 10 mg at night (the optimal dose is unknown)  [50] 
• 
Vitamin D3 2000–4000 IU/day. Calcifediol 0.2 mg is an alternative. [66] 
• 
Highly recommended: Ivermectin 0.15–0.2 mg/kg orally (repeat on day 3). [1-5,63,67-78]  See 
Table 1, Figure 5 and ClinTrials.gov NCT04523831. See drug-drug interactions above.  
• 
ASA 81–325 mg/day (unless contraindicated). ASA has antiinflammatory, antithrombotic, and 
antiviral effects.[79,80] Platelet activation may play a major role in propagating the 
prothrombotic state associated with COVID-19. [81] 
• 
B complex vitamins 
• 
Optional: Famotidine 40 mg BID (reduce dose in patients with renal dysfunction) [82-88]. 
• 
Optional: Vascepa (Ethyl eicosapentaenoic acid) 4g daily or Lovaza (EPA/DHA) 4g daily; 
alternative DHA/EPA 4g daily. Vascepa and Lovaza tablets must be swallowed and cannot be 
crushed, dissolved or chewed.  Omega-3 fatty acids have anti-inflammatory properties and play 
an important role in the resolution of inflammation. In addition, omega-3 fatty acids may have 
antiviral properties. [32,89-92] 
• 
Optional: Interferon-α/β  s/c, nasal spray or inhalation. [93-96] It should be noted that Zinc 
potentiates the effects of interferon.[97,98]  
• 
In symptomatic patients, monitoring with home pulse oximetry is recommended (due to 
asymptomatic hypoxia).  The limitations of home pulse oximeters should be recognized, and 
validated devices are preferred.[99] Multiple readings should be taken over the course of the 
day, and a downward trend should be regarded as ominous.[99] Baseline or ambulatory 
desaturation < 94% should prompt hospital admission. [100]  The following guidance is 
suggested: [99] 
 
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o Use the index or middle finger; avoid the toes or ear lobe 
o Only accept values associated with a strong pulse signal 
o Observe readings for 30–60 seconds to identify the most common value 
o Remove nail polish from the finger on which measurements are made 
o Warm cold extremities prior to measurement 
• 
Not recommended: Hydroxychloroquine (HCQ). The use of HCQ is extremely controversial.[101] 
The best scientific evidence to date suggests that HCQ has no proven benefit for post exposure 
prophylaxis, for the early symptomatic phase and in hospitalized patients. [102-120] Considering 
the unique pharmacokinetics of HCQ, it is unlikely that HCQ would be of benefit in patients with 
COVID-19 infection (it takes 5–10 days to achieve adequate plasma and lung 
concentrations).[112,121-123] Finally, it should be recognized that those studies which are 
widely promoted to support the use of HCQ are severely methodologically flawed.[124-127]  
• 
Not recommended: Systemic or inhaled corticosteroids (budesonide). In the early symptomatic 
(viral replicative phase), corticosteroids may increase viral replication and disease severity.[128] 
An OpenSAFELY analysis in patients with COVID-19 demonstrated a higher risk of death in COPD 
and asthmatic patients using high dose ICS. [129] The role of ICS in the pulmonary phase is 
unclear as patients require systemic corticosteroids to dampen the cytokine storm, with ICS 
having little systemic effects.   
 
 
 
 
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Mildly Symptomatic patients (on floor/ward in hospital): 
• 
Vitamin C 500–1000 mg q 6 hourly and Quercetin 250–500 mg BID (if available) 
• 
Zinc 75–100 mg/day 
• 
Melatonin  10 mg at night (the optimal dose is unknown) [50] 
• 
Vitamin D3 20,000–60,000 IU single oral dose. Calcifediol 0.2–0.5 mg is an alternative. [66] This 
should be followed by 20,000 IU D3 (or 0.2 mg calcifediol) weekly until discharged from hospital. 
Calcifediol is more efficiently absorbed, achieves 25-OH vitamin D levels quicker and is three 
times more potent than vitamin D3. [130,131] However, it is important to note that the optimal 
dose of vitamin D in the acute setting is unknown.[132,133] Very high doses may paradoxically 
block the vitamin D receptor.   
• 
Highly recommended: Ivermectin 0.15–0.2 mg/kg orally (12 mg) and repeat on day 3 [1-5,63,67-
77]. It should be noted that ivermectin has potent anti-inflammatory properties apart from its 
antiviral properties.[134-136]  See Table 1 and Figure 5. See drug-drug interaction above.  
• 
Enoxaparin 60 mg/day [75,137-150] Consider increasing the dose to 1mg/kg q 12 hourly in those 
with a high D-Dimer or an increasing D-Dimer (see Xa monitoring below). 
• 
ASA 325 mg (if not contraindicated). Moderate-severe COVID infection results in profound 
platelet activation contributing to the pro-thrombotic state and increasing the inflammatory 
response.[151-153]   
• 
Methylprednisolone 40 mg q 12 hourly; increase to 80 mg and then 125 mg q 12 hourly in 
patients with progressive symptoms and increasing CRP. There is now overwhelming and 
irrefutable evidence that corticosteroids reduce the risk of death in patients with the pulmonary 
phase of COVID-19 i.e. those requiring supplemental oxygen or higher levels of support. [154-
166]  The role of inhaled corticosteroids (budesonide) is unclear and appears to be rather 
limited.  
• 
B complex vitamins 
• 
Optional: Famotidine 40 mg BID (20–40 mg/day in renal impairment). [82-88] 
• 
Optional: Vascepa (Ethyl eicosapentaenoic acid) 4g daily or Lovaza (EPA/DHA) 4g daily; 
alternative DHA/EPA 4g daily.  
• 
Optional (not recommended): Remdesivir 200 mg IV loading dose D1, followed by 100mg day IV 
for 9 days. [167,168] This agent has been reported to reduce time to recovery (based on an 
ordinal scale) in patients requiring low levels of supplemental oxygen. [168,169] The recently 
published SOLIDARITY trial demonstrated no mortality benefit of this agent in the entire 
treatment cohort or any subgroup.[170] Considering the high cost of this agent and the lack of 
benefit on patient centered outcomes the role of this drug seems very limited.  
• 
N/C 2L/min if required (max 4 L/min; consider early t/f to ICU for escalation of care). 
• 
Avoid Nebulization and Respiratory treatments. Use “Spinhaler” or MDI and spacer if required. 
• 
T/f EARLY to the ICU for increasing respiratory signs/symptoms, increasing oxygen requirements 
and arterial desaturation. 
 
 
 
 
 
 
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Progressive Respiratory symptoms (hypoxia- requiring N/C ≥ 4 L min: admit to ICU): 
Essential Treatment (dampening the STORM); MATH + [171] 
1. 
Methylprednisolone 80 mg loading dose then 40 mg q 12 hourly for at least 7 days and until 
transferred out of ICU.  In patients with an increasing CRP or worsening clinical status increase the 
dose to 80 mg q 12 hourly (then 125mg q 12 hourly), then titrate down as appropriate. [154-166] 
Pulse methylprednisolone 250–500 mg mg/day may be required.[164]  As depicted in Table 1, 
methylprednisolone is the corticosteroid of choice.  
2. 
Ascorbic acid (Vitamin C) 3g IV q 6 hourly for at least 7 days and/or until transferred out of 
ICU.[27,172-183]. Note caution with POC glucose testing (see below). Oral absorption is limited by 
saturable transport and it is difficult to achieve adequate levels with PO administration. Should IV 
Vitamin C is not available, attempts should be made to administer PO vitamin C at a dose of 1g 
every 4–6 hours.  Mega-dose vitamin C should be considered in severely ill patients and as salvage 
therapy: 25g vitamin C in 200-500 cc saline over 6 hours daily for 4 days, then 3g IV q 6 hourly for 
total of 7-10 days of treatment. [184] (also see https://www.youtube.com/watch?v=Au-
mp6RZjCQ ) 
3. 
Full anticoagulation: Unless contraindicated we suggest FULL anticoagulation (on admission to 
the ICU) with enoxaparin, i.e., 1 mg kg s/c q 12 hourly (dose adjust with Cr Cl < 30mls/min). There 
is now good evidence that high intensity anticoagulation reduces mortality of hospitalized 
patients with COVID-19. [137,139,140,142-150,185]   Heparin is suggested with CrCl < 15 ml/min. 
Due to augmented renal clearance patients may have reduced anti-Xa activity despite standard 
dosages of LMWH.[186] We therefore recommend monitoring anti-Xa activity in underweight and 
obese patients, those with chronic renal failure and in those patients with an increasing D-dimer, 
aiming for an anti-Xa activity of 0.6–1.1 IU.ml.    
 
Note: A falling SaO2 and the requirement for supplemental oxygen should be a trigger to start anti-
inflammatory treatment (see Figure 2).  
 
Note: Early termination of ascorbic acid and corticosteroids will likely result in a rebound effect with 
clinical deterioration (see Figure 6). 
Additional Treatment Components (the Full Monty) 
4. 
Highly recommended: Ivermectin 0.15–0.2 mg/kg orally and repeat on day 2 (see doing above). 
[1-3,67,70-78,134-136,187-193] Note that ivermectin has potent antiviral and ant-inflammatory 
effects. See Table 1 and Figure 5. 
5. 
Melatonin 10 mg at night (the optimal dose is unknown). 
6. 
Calcifediol 0.2–0.5 mg. [66] This should be followed by 0.2 mg calcifediol weekly until discharged 
from hospital. Vitamin D3 takes many days to be converted to 25OH vitamin D; [194] this may 
explain the lack of benefit of D3 in patients hospitalized with severe COVID-19. [195] 
7. 
Thiamine 200 mg IV q 12 hourly [196-201] Thiamine may play a role in dampening the cytokine 
storm. [197] 
8. 
ASA 325 mg.  COVID infection results in profound platelet activation contributing to the severe 
pro-thrombotic state and increasing the inflammatory response.[151-153]  As the risk of 
significant bleeding is increased in patients receiving both ASA and heparin, ASA should therefore 
not be used in patients at high risk of bleeding. In addition (as noted below) patients should 
receive famotidine concurrently.  
9. 
B complex vitamins 
10. 
Magnesium: 2 g stat IV. Keep Mg between 2.0 and 2.4 mmol/l. [59]  Prevent hypomagnesemia 
(which increases the cytokine storm and prolongs Qtc). [202-204] 
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11. 
Optional: Doxycycline 100mg daily for 5 days. Doxycycline is a broad-spectrum antibiotic which 
has synergistic anti-viral and anti-inflammatory effects when combined with Ivermectin. 
[6,68,73,205] 
12. 
Optional (Consider in severe cases). Anti-serotonin agents. Platelet activation results in the release 
of serotonin, which may contribute to the “cytokine storm”. [206]Therefore, the serotonin 
receptor blocker cyproheptadine 4–8 mg PO q 6 hours should be considered.  
13. Optional. Atorvastatin 80 mg/day.  Statins have pleotropic anti-inflammatory, immunomodulatory, 
antibacterial, and antiviral effects. In addition, statins decrease expression of PAI-1. Simvastatin has 
been demonstrated to reduce mortality in the hyper-inflammatory ARDS phenotype. [207] 
Preliminary data suggests atorvastatin may improve outcome in patients with COVID-19.[208-212] 
Due to numerous drug-drug interactions simvastatin should be avoided.   
14.  Optional: Famotidine 40 mg BID (20–40 mg/day in renal impairment). [82-88]. 
15. Optional: Vascepa, Lovaza or DHA/EPA 4g day (see above).  
16. Not recommended:  The role of azithromycin in the treatment of COVID-19 is controversial. The best 
information to date suggests that azithromycin is of little benefit.[213,214] 
17. Not recommended: Remdesivir. Has not benefit at this stage of the disease. 
18. Not recommended. Convalescent serum [215,216] or monoclonal antibodies. (Eli Lilly recently 
announced that they are suspending their ACTIV-33 clinical trial as their monoclonal antibody failed 
to demonstrate a clinical benefit in hospitalized patients). 
19. Not recommended. Tocilizumab. Four RCTS have now failed to demonstrate a clinical benefit from 
tocilizumab. [217-220] 
20. Broad-spectrum antibiotics if superadded bacterial pneumonia is suspected based on procalcitonin 
levels and resp. culture (no bronchoscopy). Due to the paradox of hyper-inflammation and immune 
suppression (a major decrease of HLA-DR on CD14 monocytes and T cell dysfunction) secondary 
bacterial and fungal infection is not uncommon. [221] 
21. Maintain EUVOLEMIA (this is not non-cardiogenic pulmonary edema). Due to the prolonged 
“symptomatic phase” with flu-like symptoms (6–8 days) patients may be volume depleted. Cautious 
rehydration with 500 ml boluses of Lactate Ringers may be warranted, ideally guided by non-
invasive hemodynamic monitoring. Diuretics should be avoided unless the patient has obvious 
intravascular volume overload. Avoid hypovolemia.    
22. Early norepinephrine for hypotension. It should however be appreciated that despite the cytokine 
storm, vasodilatory shock is distinctly uncommon in uncomplicated COVID-19 (when not 
complicated by bacterial sepsis). This appears to be due to the fact that TNF-α which is “necessary” 
for vasodilatory shock is only minimally elevated.   
23. Escalation of respiratory support (steps); Try to avoid intubation if at all possible, (see Figure7) 
• Accept “permissive hypoxemia” (keep O2 Saturation > 84%); follow venous lactate and 
Central Venous O2 saturations (ScvO2) in patents with low arterial O2 saturations 
• N/C  1–6 L/min 
• High Flow Nasal canula (HFNC) up to 60–80  L/min 
• Trial of inhaled Flolan (epoprostenol) 
• Attempt proning (cooperative repositioning-proning) [222,223] 
• Intubation … by Expert intubator; Rapid sequence. No Bagging; Full PPE. Crash/emergency 
intubations should be avoided.  
• Volume protective ventilation; Lowest driving pressure and lowest PEEP as possible. Keep 
driving pressures < 15 cm H2O.  
• Moderate sedation to prevent self-extubation 
• Trial of inhaled Flolan (epoprostenol) 
• Prone positioning.   
 
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There is widespread concern that using HFNC could increase the risk of viral transmission. There is 
however, no evidence to support this fear. HFNC is a better option for the patient and the health 
care system than intubation and mechanical ventilation.  CPAP/BiPAP may be used in select 
patients, notably those with COPD exacerbation or heart failure. 
 
A sub-group of patients with COVID-19 deteriorates very rapidly. Intubation and mechanical 
ventilation may be required in these patients.  
 
 
Table 2: Comparison of Methylprednisolone, Dexamethasone and Hydrocortisone- Number 
Need to Treat (NNT) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Figure 5. Metaanalysis of Ivermectin clinical studies (in hospital mortality) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
24. Salvage Treatments 
• High dose bolus corticosteroids; 250–500 mg/day methylprednisolone [162,164] Plasma 
exchange [224-230].  Should be considered in patients with progressive oxygenation failure 
despite corticosteroid therapy as well as in patients with severe MAS. Patients may require 
up to 5 exchanges. FFP is required for the exchange; giving back “good humors” appears to 
be more important than taking out “bad humors”. 
• Mega-dose vitamin C should be considered in severely ill patients and as salvage therapy: 25g 
vitamin C in 200-500 cc saline over 6 hours daily for 4 days, then 3g IV q 6 hourly for total of 
7-10 days of treatment. [181] (also see https://www.youtube.com/watch?v=Au-mp6RZjCQ) 
• In patients with a large dead-space ventilation i.e. high PaCO2 despite adequate minute 
ventilation consider “Half-dose rTPA” to improve pulmonary microvascular blood flow; 25mg 
of tPA over 2 hours followed by a 25mg tPA infusion administered over the subsequent 22 
hours, with a dose not to exceed 0.9 mg/kg followed by full anticoagulation.[231,232] 
• ECMO [233,234]. Unlike “typical ARDS” COVID-19 patients do not progress into a resolution 
phase. Rather, patients with COVID-19 may progress to a severe fibro-proliferative phase and 
ventilator dependency. ECMO in these patients would likely serve little purpose. ECMO 
however may improve survival in patients with severe single organ failure (lung) if initiated 
within 7 days of intubation. [235] 
• Combination inhaled nitric oxide (or epoprostenol) and intravenous almitrine. The 
combination of inhaled nitric oxide, a selective pulmonary vasodilator, and almitrine, a 
specific pulmonary vasoconstrictor, may improve the severe V/Q mismatch in patients with 
severe COVID-19 “pneumonia”. [236-239] 
 
 
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Figure 6. Premature discontinuation of corticosteroids and IV vitamin C (after 4 day) and the effect of 
reinitiation of this combination on the CRP profile.  
 
 
 
 
 
 
 
 
 
 
 
 
 
Salvage treatments of unproven/no benefit.  
• Convalescent serum/monoclonal antibodies: the role and timing of convalescent serum and 
monoclonal antibodies are uncertain. [240-243] Two RCT’s failed to demonstrate any clinical 
benefit with convalescent serum. [215,216] In addition, Eli Lilly recently announced that they 
are suspending their ACTIV-33 clinical trial as their monoclonal antibody failed to 
demonstrate a clinical benefit in hospitalized patients.  It is noteworthy that the only RCT 
demonstrating efficacy of convalescent plasma for an infectious disease was conducted more 
than 40 years ago, for treating Argentine hemorrhagic fever. [211] Furthermore, giving 
antibodies directed against SARS-CoV-2 appears pointless when the virus is already DEAD 
(pulmonary phase). In addition, IgG is a large protein which penetrates tissues poorly, and is 
unlikely to achieve submucosal concentrations required for mucosal immunity.[244] And 
lastly, COVID-19 pulmonary disease is immune mediated, and it would therefore appear 
paradoxical to enhance the antibody response with convalescent serum. [245]   
• Janus Kinase inhibitors downregulate cytokine expression and may have a role in this disease. 
[246-248] The role of the combination of Baricitinib and Remdesivir is unclear.[249] 
• In patients with progressive fibrosis the combination of anti-fibrotic therapy with 
corticosteroids should be considered. [250-253] It should however be recognized that unlike 
all the medications in the MATH+ protocol, pirfenidone and nintedanib have complex side-
effects and drug interactions and should be prescribed by pulmonary physicians who have 
experience with these drugs.  
• CVVH/D with cytokine absorbing/filtering filters [254,255] This treatment strategy appears to 
have a very limited role.  
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25. Treatment of Macrophage Activation Syndrome (MAS) 
• A sub-group of patients will develop MAS, particularly those patients with severe COVID-19 
disease.[256] While the pathophysiology of MAS in the setting of COVID-19 is unclear this  
appears to be driven by SARS-CoV-2 induced inflammasome activation and increased IL-18 
production as well as increased GM-CSF and INFγ production. [257-260] The role of IL-1 and 
IL-6 in the pathogenesis of MAS is unclear.  
• A ferritin > 4400 ng/ml is considered diagnostic of MAS. Other diagnostic features include 
increasing AST/ALT and CRP and progressive multi-system organ failure.[261] 
• “High dose corticosteroids.” Methylprednisolone 120 mg q 6–8 hourly for at least 3 days, 
then wean according to Ferritin, CRP, AST/ALT (see Figure 8). Ferritin should decrease by at 
least 15% before weaning corticosteroids.  
• Consider plasma exchange. 
• The role of inhibition of IL-1 (Anakinra) and IFNγ (emapalumab) is unclear (NCT04324021). 
 
26. Monitoring 
• On admission:  Procalcitonin (PCT), CRP, BNP, Troponins, Ferritin, Neutrophil-Lymphocyte 
ratio, D-dimer and Mg.  CRP and D-dimer are important prognostic markers. A PCT is 
essential to rule out coexisting bacterial pneumonia. 
• Daily: CRP, Ferritin, D-Dimer and PCT. CRP and Ferritin track disease severity closely (although 
ferritin tends to lag behind CRP). Early high CRP levels are closely associated with the degree 
of pulmonary involvement and the CT score. [262]  
• In patients receiving IV vitamin C, the Accu-Chek™ POC glucose monitor will result in 
spuriously high blood glucose values. Therefore, a laboratory glucose is recommended to 
confirm the blood glucose levels. [263,264] 
• No routine CT scans, follow CXR and chest ultrasound. 
• ECHO as clinically indicated; Pts may develop a severe “septic” cardiomyopathy. 
 
 
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Figure 7. 
 
 
 
 
 
 
 
 
 
 
 
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Figure 8. SARS-CoV-2 induced Macrophage Activation Syndrome (MAS) treated with Vitamin 
C 3g IV q 6 and increased methylprednisolone (125 mg q 8 hourly)  
 
 
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27. Post ICU management 
 
a. Enoxaparin 40–60 mg s/c daily 
b. Methylprednisolone 40 mg day, then wean slowly (follow CRP) 
c. 
Vitamin C 500 mg PO BID 
d. Melatonin 3–6 mg at night 
e. Vascepa, Lovaza or DHA/EPA 4g day (important for resolution of inflammation) 
 
28. Post Hospital Discharge management 
 
a. Patients have an increased risk of thromboembolic events post-discharge. [265] Extended 
thromboprophylaxis (? with a DOAC) should be considered in high risk patients. Risk factors 
include:[266] 
i. 
Increased D dimer (> 2 times ULN) 
ii. 
Increased CRP (> 2 times ULN) [267] 
iii. 
Age > 60 
iv. 
Prolonged immobilization 
 
b. The post-COVID-19 syndrome (long haul syndrome), is characterized by prolonged malaise, 
headaches, generalized fatigue, painful joints, dyspnea, chest pain and cognitive 
dysfunction.[268-273] Up to 50% of patients experience prolonged illness after Covid-19. The 
post-COVID-19 syndrome may persistent for months after the acute infection and almost 
half of patients report reduced quality of life.  The neurological symptoms may be related 
micro- and/or macrovascular thrombotic disease which appears to be common in severe 
COVID-19 disease.[256]  Brain MRIs’ 3 months post-infection demonstrated micro-structural 
changes in 55% of patients. [274]   Similar to patients who have recovered from septic shock, 
[275] a prolonged (many months) immune disturbance with elevated pro- and anti-
inflammatory cytokines may contribute to the post-COVID-19 syndrome.  Consequently, A 
CRP should be measured prior to discharge and a tapering course of corticosteroids should 
be considered in those with an elevated CRP.  It should be noted that much like omega-3 
fatty acids corticosteroids have been demonstrated to increase expression of pro-resolving 
lipids including Protectin D1 and Resolvin D4.[276]  Other interventions that should be 
considered include: 
i. 
Vascepa, Lovaza or DHA/EPA 4g day; important for resolution of inflammation by 
inducing resolvin production. [91,92] 
ii. 
Atorvastatin 40 mg daily (increase resolvin synthesis) [277] 
iii. 
Continue melatonin for its antioxidant properties and stabilization of the circadian 
rhythms.  
iv. 
Multivitamin with adequate vitamin D.  
v. 
Recently Ivermectin has been reported to have a role in the treatment of post-
Covid-19 syndrome. [278] The anti-inflammatory properties of ivermectin may 
mediate this benefit.  
 
c. 
Post-COVID-19 pulmonary fibrosis. An unknown number of patients who have recovered 
from COVID-19 organizing pneumonia will develop pulmonary fibrosis with associated 
limitation of activity. These patients should be referred to a pulmonologist with expertise in 
pulmonary fibrosis. Anti-fibrotic therapy may have a role in these patients, [250-253]  
however additional data is required before this therapy can be more generally 
recommended.  
 
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29.              Maintaining mental health and the avoiding the misinformation pandemic 
 
         ‘Misinformation on the Coronavirus might be the most contagious thing about it” 
Dr. Tedros, WHO Director General 
 
• 
The Panic and misinformation spread by Social Media travels faster than the pandemic 
itself.  What you can do? 
o Avoid social media as much as possible; excess social media exposure increases 
the likelihood of anxiety and depression[279]  
o Read the news/information from reliable sources (if you can find one) 
o Have a designated time for checking information 
o People share false claims about COVID-19 partly because they simply fail to 
think sufficiently about whether or not the content is accurate when deciding 
what to share. [280] 
o Stay connected to positive people! Remotely! 
o Have a plan for staying in touch with family and friends  
o Identify positive influencers…limit contact with other “worriers”  
o Isolation can cause rumination/anxious thinking to escalate 
o Maintain a sense of hope, humanity and kindness toward others 
o Seek professional help if anxiety is overwhelming 
• 
Recognize the things you can control 
o WEAR A MASK when in contact with others 
o Establish social distancing; stand/sit about 6 feet away from others 
o Limit attendance at large gatherings 
o Eliminate your contact with those who are ill 
o DON’T go to work or school if you are sick 
o Practice self-care 
 
Good sleep, balanced diet, exercise 
 
Mindfulness/Meditation/Relaxation activities 
 
 
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Key Concepts of the FLCCC Alliance Treatment Protocol  
This is a very complex disease; many of the mysteries are still unravelling. However, a number of 
concepts are key to the management of this “treatable disease; they include. 
 
1. Patients transition through a number of different phases (clinical stages). The treatment of each 
phase is distinct ... this is critically important (see Figures 1 & 2).  
2. Antiviral therapy is likely to be effective only during the viral replicative phase whereas anti-
inflammatory therapy is expected to be effective during the pulmonary phase and possibly the 
post-COVID-19 phase. While Remdesivir is a non-specific antiviral agent that targets RNA 
viruses, it is likely that agents specifically designed to target SARS-CoV-2 will be developed.  
3. The SARS-CoV-2 PCR remains positive for at least 2 weeks following detection of whole virus (by 
culture, See figure 3). Patients who progress to the pulmonary phase are usually PCR positive 
despite cessation of viral replication (and are therefore less likely to be infectious).  
4. Due to the imperfect sensitivity of the PCR test as many as 20% of patients who progress to the 
pulmonary phase will be PCR negative (even on repeat testing). At symptom onset PCR will be 
positive in approximately 60% of patients; maximal positivity rate is on day 8 (post infection) 
when 80% of patients will be positive (see Figure3). [281]  
5. Symptomatic patients are likely to be infectious during a narrow window starting 2–3 days 
before the onset of symptoms and to up to 6 days after the onset of symptoms (see Figure 
3).[282]  
6. It is important to recognize that COVID-19 patients present with a variety of phenotypes, likely 
dependent on inoculum size and viral load, genetic heterogeneity mutations and 
polymorphisms, biotypes, blood type, sex and androgen status, age, race, BMI (obesity), 
immunological and nutritional status, and co-morbidities.[157,283-293] The phenotype at 
presentation determines the prognosis and impacts the optimal approach to treatment.  
7. The pulmonary phase is characterized by immune dysregulation, [246,248,256,259,260,286,294-
303]  a pulmonary microvascular injury (vasculopathy),[256,303-306] with activation of clotting 
and a pro-coagulant state together with the characteristics of an organizing pneumonia. 
[307,308]  
8. Endothelial damage and an imbalance of both innate and adaptive immune responses, with 
aberrant macrophage activation, plays a central role in the pathogenesis of the severe COVID-19 
Disease. [256] 
9. As patients, progress down the pulmonary cascade the disease becomes more difficult to 
reverse. The implications of this are twofold. 
a. Early treatment (of the pulmonary phase) is ESSENTIAL to a good outcome. 
b. Treatment in the late pulmonary phase may require escalation of the dose of 
corticosteroids as well as the use of salvage methods (i.e. plasma exchange). However, 
patients who present in the late pulmonary phase may have progressed to the 
irreversible pulmonary fibroproliferative phase (see Figure 9).  
10. The pulmonary phase of COVID-19 is a treatable disease; it is inappropriate to limit therapy to 
“supportive care” alone. Furthermore, it is unlikely that there will be a single “silver bullet” to 
treat severe COVID-19 disease. Rather, patients will require treatment with multiple 
drugs/interventions that have synergistic and overlapping biological effects. Repurposed FDA 
approved drugs that are safe, inexpensive, and “readily” available are likely to have a major 
therapeutic effect on this disease. The impact of COVID-19 on middle- and low-income countries 
is enormous; these countries are not able to afford expensive propriety “designer” molecules. 
11. The radiographic and pathological finding of COVID-19 lung disease are characteristic of a 
secondary organizing pneumonia (and not ARDS). [307,309,310]  
 
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12. THIS is NOT ARDS (at least initially). The initial pulmonary phase neither looks like, smells like 
nor is ARDS.[311-313] The ground glass infiltrates are peripheral and patchy, [309] and do not 
resemble the dependent air space consolidation (sponge/baby lung) seen with “typical 
ARDS”.[314]  Extravascular lung water index (EVLWI) is normal or only slightly increased; this by 
definition excludes non-cardiogenic pulmonary edema (ARDS). Lung compliance is normal (this 
excludes ARDS). Patients are PEEP unresponsive. Treating patients as if they ARDS is a very 
dangerous approach. The hypoxia is due to severe ventilation/perfusion mismatch likely due to 
the microvascular narrowing, thrombosis and vasoplegia.  
13. The core principles of the pulmonary phase (MATH+) is the use of anti-inflammatory agents to 
dampen the “cytokine storms” together with full anticoagulation to limit the microvascular and 
macrovascular clotting and supplemental oxygen to help overcome the hypoxia.  
14. Ivermectin has emerged as the “wonder drug” to prophylaxis and treat COVID-19. Ivermectin 
inhibits viral replication and has potent anti-inflammatory properties. Emerging clinical data 
(including RCT’s) suggest that ivermectin may have an important clinical benefit across the 
spectrum of phases of the disease, i.e pre-exposure prophylaxis, postexposure prophylaxis, 
during the symptomatic phase and during the pulmonary phase. [1-3,67,70-77,134-136,187-
193,315]  In the recommended dosages, Ivermectin is remarkably safe (see Table 1 and Fig 5).  
However, as noted above there is the potential for serious drug-drug interaction.  
15. The pulmonary phase of COVID-19 is characterized by PROLONGED immune dysregulation that 
may last weeks or even months. The early and abrupt termination of anti-inflammatory agents 
will likely result in rebound inflammation (see Figure 8).[316] 
16. SARS-CoV-2 as compared to all other respiratory viruses, upregulates cytokines and chemokines 
while at the same time down regulating the expression of Interferon alpha (the hosts primary 
antiviral defence mechanism). [131,155] Low innate antiviral defenses and high pro-
inflammatory mediators contribute to ongoing and progressive lung injury. 
17. Patients in whom the cytokine storm is not “dampened” will progress into the “H phenotype” 
characterized by poor lung compliance, severe oxygenation failure and PEEP recruitability (see 
Figure 9).  Progression to this phase is exacerbated by ventilator induced lung injury (VILI).  The 
histologic pattern of the “H Phenotype” is characterized by an acute fibrinous and organizing 
pneumonia (AFOP), with extensive intra-alveolar fibrin deposition called fibrin “balls” with 
absent or minimal hyaline membranes.[288,310,317-319] Corticosteroids seem to be of little 
benefit in established AFOP. High dose methylprednisolone should be attempted in the “early 
phase” of AFOP, however many patients will progress to irreversible pulmonary fibrosis with 
prolonged ventilator dependency and ultimately death.  
18. An unknown percentage of patients with COVID-19 present with “silent hypoxia” with a blunted 
respiratory response. This phenomenon may be related to involvement of chemoreceptors of 
the carotid bodies and/or brain stem dysfunction,[320,321] and necessitates pulse oximetry in 
symptomatic patients managed at home (as discussed above).   
19. It should be recognized that LWMH has non-anticoagulant properties that are likely beneficial in 
patients with COVID-19, these include anti-inflammatory effects and inhibition of histones.[322] 
in addition, in vitro studies demonstrate that heparin inhibits SARS-CoV-2 interaction with the 
ACE-2 receptor and viral entry,[323,324] as well as viral replication [75,138].  Most importantly 
LWWH inhibits heparanase (HPSE).[325] HSE destroys the endothelial glycocalyx increasing 
endothelial leakiness, activating clotting and potentiating  endothelialitis.[325]  HPSE levels have 
been reported to be increased in patients with severe COVID-19 infection. [326] 
20. Due to the ease of administration, greater anti-Xa activity and better safety profile we prefer 
low molecular weight heparin (LMWH) to unfractionated heparin (UFH). 
21. The combination of steroids and ascorbic acid (vitamin C) is essential. Both have powerful 
synergistic anti-inflammatory actions. [173,181] Vitamin C protects the endothelium from 
oxidative injury.[174,327-329]  Furthermore, vitamin C Increases the expression of interferon-
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alpha [26] while corticosteroids (alone) decease expression of this important protein. [330-
333] It should be noted that when corticosteroids are used in the pulmonary phase (and not in 
the viral replicative phase) they do not appear to increase viral shedding or decrease the 
production of type specific antibodies. [159,334]   It is likely that heparin (LMWH) acts 
synergistically with corticosteroids and vitamin C to protect the endothelium and treat the 
endothelialitis of severe COVID-19 disease.  
22. Notwithstanding the very important and impressive results of the Recovery-Dexamethasone 
study, methylprednisolone is the corticosteroid of choice for the pulmonary phase of COVID-19. 
This is based on pharmacokinetic data (better lung penetration),[335] genomic data specific for 
SARS-CoV-2,[336] and a long track record of successful use in inflammatory lung diseases. (see 
Table 1)  
23. For prophylaxis and treatment of the early symptomatic phase we suggest the combination of 
Quercetin (a plant polyphenol), Vitamin C and Zinc.[35] This is based on intriguing basic science 
data which indicates that: 
a. Zinc is essential for innate and adaptive immunity.[52] In addition, Zinc inhibits RNA 
dependent RNA polymerase in vitro against SARS-CoV-2 virus.[51]   
b. Quercetin has direct viricidal properties against a range of viruses, including SARS-CoV-
2, and is a potent antioxidant and anti-inflammatory agent. [24,29,34,34,337-344] In 
addition, quercetin acts as a zinc ionophore. [345] 
c. Vitamin C improves the potency of Quercetin and has antiviral and anti-inflammatory 
activity.[24] 
24. It should also be noted that Vitamin D may be an enormously powerful prophylactic strategy 
against COVID-19.  Vitamin D deficiency explains, in part, the enormous geographic variation in 
mortality of this disease. [11,346] It is likely that vitamin D supplementation may have a greater 
role in the prophylaxis than the treatment of severe disease.  
 
 
 
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Figure 9. The consequences of “steroid” avoidance”. CT scan after 23 days of “supportive 
care” demonstrating the late fibroproliferative (irreversible) phase of COVID-19 lung disease 
(Image kindly provide by Dr. Pierre Kory, from NYC).   
 
 
 
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Scientific Rationale for MATH+ Treatment Protocol (pulmonary phase)  
 
Three core pathologic processes lead to multi-organ failure and death in COVID-19: 
 
1) Hyper-inflammation (“Cytokine storm”) – a dysregulated immune system whose cells infiltrate 
and damage the lungs as well as other organs including the heart and bone marrow. It is now 
widely accepted that SARS-CoV-2 causes aberrant T lymphocyte and macrophage activation 
resulting in a “cytokine storm.”  [246,248,259,260,286,294,296-302]  In addition, post-mortem 
examination has demonstrated features of the “macrophage activation syndrome”, with 
hemophagocytosis and a hemophagocytic lymphohistiocytosis-like disorder.[256]   
2) Hyper-coagulability (increased clotting) – the dysregulated immune system damages the 
endothelium and activates blood clotting, causing the formation of micro and macro blood clots. 
Clotting activation may occur directly due to increased expression of Factor Xa as well as 
endothelial injury with the release of large aggregates of van Willebrand factor.[81] These blood 
clots impair blood flow. [139,140,142-150,305,306,347,348]   It should be noted that the 
thrombotic microangiopathy appears to target predominantly the pulmonary and cerebral 
circulation. [256] 
3) Severe Hypoxemia (low blood oxygen levels) –lung inflammation caused by the cytokine storm, 
together with microthrombosis in the pulmonary circulation severely impairs oxygen absorption 
resulting in oxygenation failure.   
 
The above pathologies are not novel, although the combined severity in COVID-19 disease is 
considerable. Our long-standing and more recent experiences show consistently successful treatment if 
traditional therapeutic principles of early and aggressive intervention is achieved, before the onset of 
advanced organ failure.  It is our collective opinion that the historically high levels of morbidity and 
mortality from COVID-19 is due to a single factor: the widespread and inappropriate reluctance amongst 
hospitalists and intensivists to employ anti-inflammatory and anticoagulant treatments, including 
corticosteroid therapy early in the course of a patient’s hospitalization.   It is essential to recognize that 
it is not the virus that is killing the patient, rather it is the patient’s overactive immune system. 
[245,248,256,321]  Autopsy studies have demonstrated minimal viral cytopathic effects.[256,321]  The 
flames of the “cytokine fire” are out of control and need to be extinguished. Providing supportive care 
(with ventilators that themselves stoke the fire) and waiting for the cytokine fire to burn itself out simply 
does not work… this approach has FAILED and has led to the death of tens of thousands of patients.    
 
    “If what you are doing ain’t working, change what you are doing” – PEM 
 
The systematic failure of critical care systems to adopt corticosteroid therapy (early in this pandemic) 
resulted from the published recommendations against corticosteroids use by the World Health 
Organization (as recent as May 27th 2020) [349,350]. This recommendation was then perpetuated by the 
Centers for Disease Control and Prevention (CDC), the American Thoracic Society (ATS), Infectious 
Diseases Association of America (IDSA) amongst others. A publication authored one of the members of 
the Front Line COVID-19 Critical Care (FLCCC) Alliance (UM), identified the errors made by these 
organizations in their analyses of corticosteroid studies based on the findings of the SARS and H1N1 
pandemics.[154,351] Their erroneous recommendation to avoid corticosteroids in the treatment of 
COVID-19 has led to the development of myriad organ failures which have overwhelmed critical care 
systems across the world and led to excess deaths. The recently published results of the RECOVERY-
DEXAMETHASONE study provide definitive and unambiguous evidence of the lifesaving benefits of 
corticosteroids and strong validation of the MATH + protocol. It should be recognized that 
corticosteroids are the only therapy proven to reduce the mortality in patients with COVID-19.[352] The 
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RECOVERY-DEXAMETHASONE study, randomized 2104 patients to receive dexamethasone 6 mg 
(equivalent to 32 mg methylprednisolone) once per day (either by mouth or by intravenous injection) 
for ten days and were compared with 4321 patients randomized to usual care alone.[128]  
Dexamethasone reduced deaths by one-third in ventilated patients (rate ratio 0.65 [95% confidence 
interval 0.48 to 0.88]; p=0.0003) and by one fifth in other patients receiving oxygen only (0.80 [0.67 to 
0.96]; p=0.0021). There was no benefit among those patients who did not require respiratory support 
(1.22 [0.86 to 1.75; p=0.14). The results of this study STRONGLY support the EVMS/MATH+ protocol 
which recommends the use of corticosteroids for the “pulmonary phase” of COVID-19. It should be 
noted that we would consider the non-titratable ‘fixed” dose of dexamethasone used in the RECOVERY-
DEXAMETHASONE study to be very low. Furthermore, as indicated above we consider 
methylprednisolone to be the corticosteroid of choice for the treatment of COVID-19 pulmonary 
disease. The benefit of methylprednisolone in improving respiratory function, ventilator dependency 
and mortality has been confirmed in a number of observational studies, [155,156,162,334,353-355] as 
well as a randomized controlled study.[164] It should be recognized that the mortality benefit with 
methylprednisolone was not replicated in a recent Brazilian RCT. [316] However, in this study 
methylprednisolone was started relatively late (day 13 after symptom onset), but most importantly was 
stopped on day 5. This failed study reinforces the concept of early and prolonged treatment with 
methylprednisolone titrated to the patient’s clinical response. In patients at high risk of Strongyloides 
infection, screening and/or treatment of this parasite with ivermectin is suggested prior to treatment 
with corticosteroids.[356]   
 
Our treatment protocol targeting the key pathologic processes has been highly successful,                        
if begun within 6 hours of a COVID19 patient presenting with shortness of breath and/or arterial 
desaturation and requiring supplemental oxygen. If such early initiation of treatment could be 
systematically achieved, the need for mechanical ventilators and ICU beds will decrease dramatically.  
 
 
Further resources: 
 
The reader is referred to the large autopsy series by Bruce and colleagues which clearly outlines the 
pathophysiology of severe COVID-19 disease.[256]  
 
The scientific rationale for the MATH + protocol is reviewed in this paper.[171] 
 
In this U-tube video, Professor Britt Glaunsinger, PhD provides an outstanding review on the molecular 
virology of SARS-CoV-2:  https://www.youtube.com/watch?v=DQVpHyvz4no 
Lectures by Paul Marik, MD reviewing clinical aspects of COVID-19.  
https://www.youtube.com/channel/UCz9Pvn15m4Rv1uY-aBYRVuw 
 
 
 
 
 
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