Publication date: 2024-04-20
In this research update, Dr. Patrick Nemechek reviews a single Long COVID case to illustrate how he sequences different parts of his protocol when symptoms persist after one viral event—and then flare again after a subsequent infection. The goal, as he frames it, is to control chronic inflammatory signaling that appears to remain activated in many Long COVID patients.
Dr. Nemechek emphasizes that this is a clinical discussion based on his patient experience and interpretation of emerging research, not a one-size-fits-all plan. He uses the case to show how he decides when to stay with “cycling” approaches versus when to shift to more continuous support, and how newer observations (including a second, more severe form of COVID-associated gut barrier disruption) can become the “missing piece” for some patients.
The case: symptoms that intensified after COVID
Dr. Nemechek describes a 38-year-old woman who developed COVID in January 2021. Her initial respiratory symptoms (fever and cough) were mild, but within the next one to two months she developed persistent headaches, severe brain fog, and intense anxiety. She noticed the anxiety was worse when upright for prolonged periods or when she became overheated. She also experienced hair loss, insomnia, and a level of impairment that made it difficult to care for her two children.
She came to Dr. Nemechek’s attention in October 2021, many months after the initial infection.
Dr. Nemechek’s framework: inflammation as a shared finding in Long COVID
Dr. Nemechek explains that his “basic protocol” is centered on controlling inflammation. In his description, research in Long COVID has shown that many patients—regardless of the specific symptoms they report—have high levels of inflammatory cytokines in the bloodstream, suggesting an immune system that remains “revved up and turned on.”
Within this framework, he initiated a combination that included:
- Fish oil and olive oil (as part of his core approach to inflammation control)
- Rifaximin (he references the brand name “Xifaxan” in the U.S.) given as monthly cycles—twice daily for 10 days each month
- Vagus nerve stimulation (VNS), about five minutes per day
He reports that she began to feel “quite a bit better,” but after about two to three months she plateaued. Importantly, she noticed a pattern: she felt better while taking rifaximin during the 10-day cycle, but during the ~20 days off between cycles she felt increasingly unwell—like she “needed it again.” Dr. Nemechek interprets that as a sign of relapse and ongoing inability to keep inflammation down consistently, and he says this is when he shifts patients from cycling rifaximin to continuous rifaximin.
He also describes how she noticed symptom changes if she forgot VNS for a couple of days: her anxiety would spike and her joints would start to hurt. In Dr. Nemechek’s explanation, the vagus nerve is a major mechanism the body uses to control inflammation, and there is evidence (as he states) that COVID can directly damage the vagus nerve—so it may not function well in some COVID patients. He adds that, in his experience, if inflammation is controlled long enough, the nervous system can recover and some patients may not need ongoing VNS.
When symptoms return after a second infection
After improvement and stepping back down to monthly rifaximin cycles (while continuing fish oil, olive oil, and VNS), she contracted COVID again in January 2023. Dr. Nemechek reports that her symptoms returned “much worse” than the first time. He returned her to continuous fish oil, olive oil, VNS, and rifaximin. She began improving again, but this time she did not recover as fully as she had after the initial infection.
A “missing piece”: COVID-associated hyperpermeability and glutamine support
Dr. Nemechek explains that by spring 2023, papers were emerging describing what he calls a second form of “leaky gut” associated with COVID. In the way he summarizes it, high inflammation can create a glutamine-deficient state, leading to loss of intestinal lining cells and a more severe barrier defect. He notes this is described not simply as increased permeability but as “hyperpermeability.” He also states that this phenomenon occurs in HIV disease, adding that he is an HIV specialist and worked on glutamine-related research in the 1990s.
In June 2023, based on this framework, he added glutamine supplementation to her existing regimen (continuous rifaximin, fish oil, olive oil, and VNS). He describes her response as an “awesome recovery,” calling glutamine the missing piece in her case. She reported noticing something within the first month, and during the second and third month she not only felt better in terms of recovery but also “physically felt better and stronger.”
Dr. Nemechek explains his interpretation of why that might occur: in a chronic inflammatory state, the body may “devour muscle” to obtain glutamine to fuel the immune system. He relates this to wasting syndrome he observed in men with HIV, describing skeletal thinness as muscle being consumed to support immune demand.
Backing down supports as inflammation improves
As she stabilized, Dr. Nemechek describes stepping down components. He notes that by winter 2023 they were able to stop glutamine first. In his explanation, once inflammation is down, the body can make enough glutamine again to support gut health. She did well for two to three months after stopping it.
At the last visit he references, she had backed off rifaximin again to monthly cycles. He anticipates that by summer she may be maintained on fish oil and olive oil, possibly VNS depending on how she does, with intermittent 10-day courses of rifaximin if symptoms recur along with what he describes as a relapse of SIBO.
Clinical takeaways Dr. Nemechek highlights
- In his experience, Long COVID patients he is seeing have bacterial overgrowth that responds well to rifaximin.
- He estimates that about half may also need glutamine due to the secondary, more severe gut barrier problem he describes.
- He uses symptom patterns—such as feeling noticeably worse during “off” periods—to decide when cycling support is not sufficient.
- He views VNS as a tool to support inflammation control when vagus nerve function may be impaired, with the possibility that it can be reduced later as recovery occurs.
Educational medical disclaimer: This article summarizes one clinician’s discussion of a patient case and related interpretations of emerging research. It is not medical advice and is not a substitute for diagnosis or treatment from your licensed healthcare professional. Do not start, stop, or change medications or supplements without medical guidance.
