i-MASK Protocol by FLCCC: COVID Prevention and Treatment (October 2021)

The I-Mask protocol for prevention and early treatment are physiologic-based combination treatment regimens developed by leaders in critical care medicine. All component medicines are FDA-approved, inexpensive, readily available and have been used for decades with well-established safety profiles. In October 2020, FLCCC added ivermectin as a core medication in the prevention and treatment of COVID-19.


McCullough et al. Reviews in Cardiovascular Medicine, 2020

Please check this post regularly for updates – new medications may be added and/or dose changes to existing medications may be made as further scientific studies emerge.

Current I-MASK+ protocol: version 17, updated on Sep 24, 2021.

I-MASK protocol for Prevention (for Delta variant)

Should I take ivermectin as a prophylaxis? For prevention, the Front Line COVID-19 Critical Care Working Group (FLCCC) I-MASK+ protocol recommends (September 24, 2021 version):

Anti-Virals & AntiSeptics
  • Gargle mouthwash: 2 x daily – gargle (do not swallow) antiseptic mouthwash with cetylpyridinium chloride (e.g. Scope mouthwash™, Crest mouthwashColgate 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 
    • Post COVID-19 Exposure Prevention: 0.4 mg/kg per dose (take with or after a meal)  — one dose today, repeat after 48 hours
Immune Fortifying / Supportive Therapy
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.
  • 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 ethylene glycol) that are known to cause liver failure in high doses. 
Related: 

I-MASK protocol for Early Treatment

For early outpatient protocol (COVID-19 positive), the Front Line COVID-19 Critical Care Working Group, FLCCC I-MASK+ protocol recommends (updated September 24, 2021):

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; 2) treatment started on or after day 5 of symptoms or in pulmonary phase; or 3) multiple comorbidities/risk factors.
  • and/or Nitazoxanide: 500 mg 2 x daily for 5 days after meals. Combine with ivermectin (preferred) or substitute if ivermectin is not available. (Nitazoxanide is often unavailable or high-priced in the USA)
Anti-Septic Anti-virals
  • Antiviral mouthwash: Gargle 3 x daily (do not swallow; must contain chlorhexidine,  povidone-iodine, or cetylpyridinium chloride). (e.g. Scope mouthwash™, Crest mouthwashColgate mouthwashBetadine® Antiseptic Sore Throat Gargle)
  • Iodine Nasal Spray: 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: 5,000 IU daily. Preferred forms if available: Calcitriol (Rocaltrol) 0.5 mcg on day 1, then 0.25 mcg daily for 7 days – or Calcifediol 0.5 mg on day 1, then 0.2 mg on days  3 + 7, then 0.2 mg weekly until recovered.
  • Melatonin: 10 mg before bedtime (causes drowsiness). (Amazon)
Adjunctive / Synergistic Therapies
  • Vitamin C: 500 - 1,000 mg BID (twice daily) (Amazon) (iHerb)
  • Quercetin: 250 mg twice a day. (Amazon) (iHerb)
  • Zinc: 100 mg/day. Zinc lozenges are preferred. (Amazon) (iHerb)
Nutritional Therapeutics (New)
  • Curcumin (turmeric) 500mg 2 x daily for 14 days (Amazon)
  • Nigella Sativa 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)

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.
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.

Monoclonal antibody therapy

Casirivimab/imdevimab: 600 mg each in a single subcutaneous injection for patients with one or more risk factors as follows: Age > 65y; obesity; pregnancy; chronic lung, heart, or kidney disease; diabetes; immunosuppressed; developmental disability; chronic tracheostomy; or tube feeding.

Alternatives: 
* Not available on Amazon



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