Solving the Puzzle—The Ross Long Covid Support Protocol

Published: 4/1/2024

Solving The Puzzle of Long Covid—A Root Cause Approach

Research points to various root causes at the heart of Long Covid. (1) Additionally, limited research and case studies show improvements using targeted symptom management therapies like

• low dose naltrexone for pain, fatigue and neurologic symptoms;
• beta blockers for heart symptoms;
• salt for postural orthostatic tachycardia syndrome (POTS) symptoms; and
• antihistamines for Mast Cell Activation Syndrome (MCAS).

For more information on targeted therapies research see Table 1. Summary of candidate treatments and supporting evidence from Long COVID: major findings, mechanisms and recommendations. (1)

But as of March 2024, published studies on a comprehensive root causes approach addressing the full range of Long Covid triggers do not exist.

Common Long Covid Symptoms

People with Long Covid have many of the following symptoms

• tiredness and fatigue,
• various types of thinking problems commonly called brain fog,
• worsening of fatigue or thinking after physical activity,
• sleep disturbances, and
• joint or muscle pains.

OvationLab-ANDHealth Post Viral Recovery Program Provides Direction

The Ross Long Covid Support Protocol included later in this article is based on the pioneering work of OvationLab with ANDHealth (OLAH). In 2022, OLAH convened a group of experts to review the literature to develop a root causes approach to addressing Long Covid. As part of their work, they are collecting data on 100 people who are using a Long Covid support approach they developed.

Root Causes Addressed in OLAH Post Viral Recovery Program

OLAH identified five root causes of Long Covid based on their review of the literature. These include:

• persistent covid viral infection,
• organ and vascular damage related to ACE cell receptors attacked by Covid-19,
• mitochondrial cell energy factories dysfunction,
• intestinal microbiome disruption of normal healthy bacteria, and
• chronic inflammation.

OLAH Post Viral Recovery Protocol

The OLAH approach includes a program of lifestyle interventions and nutritional supplements. Here are the basic components. 

• A plant-based diet using the Whole 30 Program which emphasizes colorful and nutrient dense foods, quality proteins and healthy fats while removing processed foods and drinks.
• Restorative sleep.
• Movement and exercise as tolerated emphasizing taking it slow by starting small and pacing activity.
• Stress modification through activities like meditation, support through others, being physically active, spending time in nature, gratitude practices, play, and creative expression in music and art.
• Social connection through support groups, family, friends and other person to person interactions.
• A program of core and additional nutritional supplements targeting ACE-2 caused tissue damage, viral persistence, chronic inflammation, mitochondria injury, and gut microbiome imbalance.

Here are the specialty supplements in OLAH.

• Arterosill by Calroy Health Sciences is a source of rahmnan sulfate to support repair of damaged blood vessels and their endothelial glycocalyx. Damaged endothelial glycocalyx can lead to poor blood flow due to decreased vascular nitric oxide production and increased blood clotting and micro-clots. *
• MegaSporeBiotic by Microbiome Labs is a spore forming probiotic to promote healthy bacteria balance and to recondition the microbes in the intestines. *
• MegaPreBiotic by Microbiome Labs provides health nutrients to promote healthy bacteria balance in the gut. *
• ITIS by Return Healthy is designed to balance chronic inflammation. *
• Tollovid from Todos Medical, an extract from Gromwell Root, is a plant-based 3CL protease inhibitor and immune system inflammation modulator that may limit persistent viral infection. The 3CL protease is used in viral replication. It is the same protease targeted in prescription Paxlovid. *

There are the following additional support supplements in OLAH.

• MitoCore by Ortho Molecular Products is a multivitamin with essential nutrients to promote healthy mitochondria cell energy production. *
• OmegaGenics by Metagenics is an Omega-3 product containing 710 mg EPA and 290 mg DHA to promote healthy inflammation levels . *
• Magnesium Glycinate support cellular and mitochondrial function.
• Co-Enzyme Q10 may assist mitochondrial function,
• Quercetin supports healthy inflammation levels and may limit viral replication, and
• Vitamin K2 with D3 supports healthy immune and hormonal systems.

For more detail about the specific products recommended in the protocol see The Post-Viral Recovery Program Supplement Protocols at Holistic Primary Care. You can also find the full protocol with recommended dosing at the Post-viral Recovery and Foundations Protocol from FullScript.

Effectiveness of OLAH Post Viral Recovery Protocol

At the A4M conference in Las Vegas in December 2023, OLAH and its panel of experts presented preliminary results on their approach. Currently OLAH has not published its findings. According to the panel presentation, about 50% of people completing the three-month OLAH protocol achieve complete healing of their Long Covid.

OLAH analyzed data of 40 people enrolled in their registry. That analysis shows functional status changes from 2 to 1.2 on a 4-point scale representing a 38.5% improvement. In addition,

• fatigue levels improved 30%,
• anxiety decreased 20%,
• depression improved 27%,
• sleep disturbances decreased 23%, and
• pain interference decreased 15%.

From what I can tell, these reported improvements include data for the 50% of people getting full recovery mixed in with the data of those getting minimal recovery. The OLAH approach looks promising especially for the 50% that get full recovery, but my interpretation of the limited data is that 50% are getting minimal to no improvements.

My Review of OLAH Post Viral Recovery Protocol

Overall, I am impressed with the relative success of the OLAH protocol. However, the study is very limited with only 40 participants included in the data interpretation. In addition, this is a cohort study that followed people through the treatment. We do not have a comparison group of people with Long Covid and similar demographics or even a placebo control group to know how many people would recover if nothing was done or as a placebo effect.

Finally, it is disappointing that 50% of people had minimal recovery at three months. This suggests that something is missing in the OLAH protocol—that there are other root causes the OLAH protocol misses or the supplements they chose to address a problem are not effective enough.

The Ross Long Covid Support Protocol

Given the shortcomings of the OLAH protocol, I have developed an improved post viral recovery program called The Ross Long Covid Support Protocol. This protocol is based on my own observations and successes treating people with Long-Covid in my Seattle practice, the OLAH experience, and my review of the science.

The Main Root Cause Differences in Ross vs OLAH Protocols

I agree with OLAH and the five root causes they identify which include:

• persistent Covid viral infection,
• organ and vascular damage related to ACE receptors attacked by Covid-19,
• mitochondrial dysfunction,
• intestinal microbiome disruption of normal healthy bacteria, and
• chronic inflammation.

In addition, there are two other root causes not identified by OLAH which include:

• immune dysregulation unrelated to gut microbiome dysfunction, mitochondrial dysfunction, and chronic inflammation; and
• serotonin depletion caused by Covid-19 and/or gut microbiome dysfunction.

Why Immune Dysregulation Matters

Immune dysregulation can lead to chronic inflammation, MCAS, and poor ability to clear viral and other infections. This dysregulation could lead to reactivation of chronic dormant tick-borne infections like Borrelia and Bartonella or even chronic viral infections like Epstein Barr Virus (EBV). The OLAH protocol addresses immune dysfunction by fixing the gut microbiome and using anti-inflammation herbs. But in my experience there are stronger ways to correct this dysfunction by working with approaches that raise Treg cells to balance TH1 and TH2 inflammation or using other supplements that support healthy TH1 and TH2 levels outright.

Low Dose Naltrexone and BPC-157. In my practice I found benefits using Low Dose Naltrexone (LDN) and BPC-157 peptide. LDN can raise healthy levels of Treg cells to modulate healthy levels of TH1 and TH2 inflammation. While peptides like BPC-157 may promote healthy TH1 and TH2. As I noted earlier there is some data supporting the use of LDN in a Long Covid protocol. LDN also binds to toll receptors on mast cells helping to stabilize these immune cells, so they are less reactive in MCAS. In MCAS mast cells are overly turned on by infections or toxins, or even allergens. MCAS is seen in Long Covid. My experience is that LDN can improve this situation.

Read more about LDN in Low Dose Naltrexone (LDN) & Lyme. Read more about peptides and BPC-157 in Key Oral Peptide Strategies to Repair and Restore in Lyme & Mold Toxicity.

Why Serotonin Depletion Matters

After OLAH developed its protocol newer science shows there is serotonin depletion. Low serotonin contributes to cognitive dysfunction, mood disorders and may cause vagal nerve dysfunction leading to autonomic dysfunction like that found in POTS. My understanding is some physicians involved in the development of the OLAH protocol now are suggesting the addition of 5 hydroxytryptophan (5 HTP) to increase serotonin levels. I agree with this addition.

5 HTP. I am including 5 HTP in the Ross Long Covid Support Protocol. 5 HTP is a building block for serotonin production. Fixing the gut microbiome can help, but adding the direct precursor for serotonin production may work better.

Additional Differences in Ross vs OLAH Protocols

I agree with the use of

• Gromwell Root (Tolovid),
• Rhamnan Sulfate (Arterosil),
• Spore Forming Probiotic (MegaSporeBiotic),
• Prebiotic (MegaPre), and
• Quercetin

recommended in the OLAH protocol.

However, I think there are stronger approaches to repair the mitochondria and safer anti-inflammation supplements to use when someone has chronic tick-borne infections. I also find there are stronger extracts of fish oil to resolve inflammation than using the specific DHA and EHA supplement recommended by OLAH.

Liposomal Curcumin, Liposomal Glutathione and Specialized Pro-Resolving Mediators. To support healthy inflammation I suggest liposomal curcumin and liposomal glutathione rather than the ITIS product. I know firsthand from working with people with tick-borne illnesses that this combination is effective in balancing unhealthy cytokine levels. My concern with ITIS is that it includes herbs like Skullcap and Cat’s Claw that could cause more inflammation from killing dormant or active tick-borne infections through a Herxheimer reaction. Additionally, rather than using Omega 3 fatty acids found in the OmaGenics, I suggest omega three fatty acid extracts that can resolve unchecked inflammation when the immune system cannot turn itself off. SPM Active by Metagenics contains fatty acid fractions called specialized pro-resolving mediators which may resolve unchecked inflammation. *

For more information about managing cytokine inflammation seen in Long Covid or tick born infections see Control Cytokines: A Guide to Fix Lyme Symptoms & The Immune System.

Mitochondria Phospholipids, Liposomal Glutathione, Mitochondrial Micronutrients and Multivitamin. To repair mitochondria, I find a nutrient approach like that in Mitocare is insufficient to repair the damaged mitochondrial membranes from inside and outside. To that end, I recommend phospholipid repair of the mitochondrial membranes with a mix of mitochondria membrane phospholipid fats like those found in ATP 360 by Researched Nutritionals. * I also suggest liposomal glutathione because it aids in the repair of mitochondria from the inside as a very powerful antioxidant. For key nutrients, I suggest the addition of a multivitamin like Physician’s Daily by Researched Nutritionals. * Both the ATP 360 and the Physician’s Daily include nutrients that support the mitochondria to operate efficiently. *

For more information about mitochondria dysfunction and repair, including the use of methylene blue see Power Up Your Mighty Mitochondria & Get Energy.

Multivitamin. For key nutrients, rather than using the magnesium, Mitocore and Vitamin D/K2 recommended by OLAH, I suggest the Physician’s Daily by Researched Nutritionals. * This also includes healthy levels of zinc, which in conjunction with quercetin may alter viral replication.

BPC-157. As noted earlier, I suggest the peptide BPC-157 to promote a healthy balance in TH1 and TH2 inflammation. But BPC-157 has many other support functions. It is also useful in promoting repair of injured tissues. In my practice, I found it helped repair injured muscles, connective tissues, and joints in my patients with tick borne illnesses. I also observed improvements in my patients with Long Covid when they had tissue injuries.

About Reactivation of Tick-Borne Infections and Chronic Virus Infections 

It is possible Acute Covid triggers dormant tick-borne infections to become active. It is also possible that chronic infections like EBV (mono virus) and CMV also become active. Correcting the root causes of Long Covid could allow the immune system to put all these infections back in check.

But if the Ross Long Covid Support Protocol does not help you after three to six months, then it is time to consider treating for reactivated chronic viruses. For more information when and how to treat chronic viruses see When & How to Treat Chronic Viruses in Lyme: A Brief Guide. The principles I lay out in the article apply to treating common chronic viruses, like EBV, in Lyme and in Long Covid.

Determining if tick-borne infections are active as part of Long Covid is more of an art than a science. The issue is there is no reliable testing that says tick-borne infections are active. I urge you to work with your Lyme literate health care practitioner to determine if you should also treat for reactivated tick-borne infections as part of your treatment of Long Covid.

Action Steps in The Ross Long-Covid Support Protocol

Part A. Lifestyle Modifications

The following lifestyle modifications and action steps come from the OLAH protocol. I cannot stress the importance of these steps enough. To implement these steps, you may need the direct help of a functional medicine health professional. You may also want the help of a health coach or even a nutritionist.

• Eat a plant-based diet using the Whole 30 Program which emphasizes colorful and nutrient dense foods, quality proteins and healthy fats while removing processed foods and drinks.
• Get restorative sleep through lifestyle modifications or sleep inducing herbal medicines. For more information see Sleep: The Basic Steps and Sleep: The Natural Medicines.
• Move and exercise as tolerated emphasizing taking it slow by starting small and pacing activity.
• Modify stress through activities like meditation, getting support with others, being physically active, spending time in nature, gratitude practices, play, and creative expression in music and art.
• Connect socially through support groups, family, friends, and other person to person interactions.

Part B. Nutritional Supplements and Medications

I understand what follows is a lot to do, but it is designed to address all the root causes of Long Covid. As the OLAH data shows, a comprehensive root cause approach provides a way forward for those living with this chronic illness. Yes, I do intend that a person will not pick and choose parts but engage the whole protocol. I urge each person to discuss this protocol with their physician or other health care provider to see if it is right for you or to get the support you will need especially with the various lifestyle recommendations included in Part A. A functional medicine or integrative medicine provider is best because they will understand a root cause approach.

If you are looking for a place to source the various products I recommend below, see The Ross Long Covid Support Protocol Aisle at Marty Ross MD Supplements.

Viral Persistence

• Gromwell Root 3 capsules 4 times a day for the first 30 days, then 2 capsules 4 times a day for 7 days then, 1 capsule 2 times a day for 30 days. If symptoms worsen after stopping or decreasing Gromwell Root, consider continuing at the last effective dose. My preferred Gromwell Root product is Tollovid by Todos Medical.

Alternatives to Gromwell Root. After I developed this article, Tollovid became unavailable. It appears the manufacturer is not sure they will return to making this product. Unfortunately, there are no other herbal alternatives. Prescription alternatives could include a 1-month trial of daily Paxlovid. There is one case study showing possible help with this approach. Another alternative with controversial findings is the use of Ivermectin. Overall, I do not think unbiased studies support Ivermectin as an effective agent in acute covid. However, I think there are compelling reasons to think it could help as an antiviral and through cytokine balancing in Long Covid. For an approach to using Ivermectin for Long-Covid see the I-RECOVER Long Covid Treatment by the FLCCC Alliance.

If you are unable to obtain Paxlovid or Ivermectin, and the Gromwell Root remains unavailable, proceed with the rest of the Ross Long Covid Support Protocol. The protocol may help the immune system to work better so that it can resolve any remaining pockets of chronic Covid-19 infection. Additionally, many with Long-Covid likely do not have persistent infection. Unfortunately, there is not a test we can do to see if a person has persistent infection.

Repair of ACE 2 Receptor Related Vascular and Tissue Injury

• Rhamnan Sulfate 2 capsules, 2 times daily for 30 days, then 1 capsule 2 times a day for 60 days. My preferred Rhamnan Sulfate product is Arterosil HP by Calroy Health Sciences. *
• BPC-157 Peptide 500 ug 2 times a day for 90 days or more if symptoms remain. My preferred product is BPC-157 Pure by Integrative Peptides. *

Note: As I wrote earlier in this article, injury to the endothelial glycocalyx may lead to micro-clots. My approach to addressing these micro-clots is to fix the underlying injury to the endothelial glycocalyx. Some practitioners advocate using fibrinolytic enzymes like Lumbrokinase to break down these micro-clots. It is possible to take Lumbrokinase 16 to 20 mg 2 times a day in addtion to the repair work with Rhamnan Sulfate I outline here. 

Intestinal Microbiome Dysbiosis

• Spore Forming Probiotic 2 capsules 1 time a day for the first 30 days. If you are herbal or prescription antibiotics to treat tick-borne illnesses remain on the spore forming probiotic while on the antibiotics. My preferred product in Long-Covid is MegaSporeBiotic by Microbiome Labs. *
• Prebiotic 3 capsules 1 time a day on days 31 to 90. Do not take this during the first 30 days of this protocol. My preferred product is MegaPre by Microbiome Labs. *

Chronic Inflammation

• Liposomal Glutathione 400 to 500 mg 1 time a day for 90 days. My preferred product is Tri-Fortify by Researched Nutritionals. *
• Liposomal Curcumin 500 mg 1 pill 3 times a day for 90 days. My preferred product is Curcumin Phytosome by Thorne. *
• Specialized Pro-resolving Mediators 2 pills one-time daily beginning 30 days after starting Gromwell Root. My preferred product is SPM Active by Metagenix. *
• Low Dose Naltrexone 1.5 to 4.5 mg 1 time a day. Use it for a minimum of 6 months to see if it is effective. Start at 1.5 mg 1 time a day in the morning for 2 weeks, then increase to 3.0 mg 1 time a day for 2 weeks, then increase to 4.5 mg 1 time a day. LDN is a prescription made by compounding pharmacies. 

Mitochondria Injury and Dysfunction

• Mitochondrial Phospholipid and Micronutrients 3 pills 1 time a day. My preferred product is ATP 360 by Researched Nutritionals. * Use for 6 months.
• Liposomal Glutathione 400 to 500 mg 1 time a day for 90 days. My preferred product is Tri-Fortify by Researched Nutritionals. *
• Multivitamin 1 capsule daily. My preferred multivitamin is Physician’s Daily by Researched Nutritionals.

Serotonin Depletion

• 5 Hydroxytryptophan 100 mg 1 pill 3 times a day for 90 days. Consult with a physician before using this with SSRI or SNRI antidepressant prescriptions. My preferred product is 5-Hydroxytryptophan by Thorne.
• Spore Forming Probiotic 2 capsules 1 time a day for the first 30 days. If you are herbal or prescription antibiotics to treat tick-borne illnesses remain on the spore forming probiotic while on the antibiotics. My preferred product in Long-Covid is MegaSporeBiotic by Microbiome Labs. *
• Prebiotic 3 capsules 1 time a day on days 31 to 90. Do not take this during the first 30 days of this protocol. My preferred product is MegaPre by Microbiome Labs. *

Immune System Dysfunction Including Mast Cell Activation Syndrome

• Quercetin 250 mg 2 pills three times a day for 90 days. My preferred product is Quercetin Phytosome by Thorne Research. I suggest Quercetin here as a mast cell stabilizer for those with MCAS. For additional approaches including anti-histamines see Mast Cell Activation Syndrome in Infections & Mold Toxicity.
• Low Dose Naltrexone 1.5 to 4.5 mg 1 time a day. Use it for a minimum of 6 months to see if it is effective. Start at 1.5 mg 1 time a day in the morning for 2 weeks, then increase to 3.0 mg 1 time a day for 2 weeks, then increase to 4.5 mg 1 time a day. LDN is a prescription made by compounding pharmacies. 
• BPC-157 Peptide 500 ug 2 times a day for 90 days or more if symptoms remain. My preferred product is BPC-157 Pure by Integrative Peptides.

Essential Micronutrients Including Vitamin D and Zinc

• Multivitamin 1 capsule daily. My preferred multivitamin is Physician’s Daily by Researched Nutritionals.

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* These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.