COVID-19 - long haulers tips - post-day8 persistent cough is one of the more difficult symptoms to reverse - most effective solution is inhaled budesonide (rotacaps)
Chronic cough of uncertain origin (could be post-COVID-19) or COVID-19 post-day8 persistent cough (long haulers) - is easily reversed with inhaled budesonide (rotacaps i.e. powdered steroids)
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DISCLAIMER: please discuss the suggestions below with your doctor
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TODO: add examples you have seen - and earlier twitter threads on this
TODO: write substack article on protocol that leads to zero long haulers
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UPDATE: Feedback on another delivery mode - liquid steroids in nebulizer. @PattieRose20 reports that in her experience - 1mg/ml nebulized budesonide - taken 2x a day - for 2 weeks - also works great:
https://x.com/PattieRose20/status/1896387651076600257?t=Bf5or5IaP_D3_X-VUTmRAw&s=19
>Budesonide, a corticosteroid, 1 mg/mL nebulized twice a day for 2 weeks worked great! I’ve never used the rotocaps.
NOTE: this may seem like a larger steroids dose, delivered for longer. However, with nebulized, there is leakage from the sides of the mask - so full dose is not going into lungs. The steroids dose delivered also depends on the dynamics of the particulates (rotacaps) vs the droplets (nebulizer). It is possible that having larger particulates ensures there is more deposition deep inside the lungs - while if droplets are too small, more maybe likely to come back up when patient exhales (?). I suspect the deposition rate for the steroids particulate in the rotacaps capsules is high i.e. it has a larger particulate size (weight scales as length cubed - while area scales as length squared - area impacts drag - so very small particulate is more likely to be carried along (drag dominates over weight) with the air current- which matches intuition or experience watching particulates - smaller particulates are likely to be carried along more) - this would suggest that smaller particulate goes into lungs with the air, but much of it also then comes right back up when exhale. Thus it is possible that rotacaps is exhibiting faster recovery - because more of it gets desposited as soon as the air that goes into lungs gets stagnant i.e. air currents drop.
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SUMMARY: post-COVID-19 cough is one of the symptoms which can persist in many patients - even when they have had a course of Prednisolone 40mg (steroids) tapering down over 2 weeks, still they may have persistent cough that doesn't go away for weeks or more. I present a solution that seems to work every time I have used it or suggested it to such patients - and that is inhaled budesonide (preferably rotacaps i.e. budesonide steroid powder which is available in capsules that are used in a plastic inhaling device - 4-5 times a day for a week is usually enough to reverse (sometimes earlier than that, and sometimes at lower doses than that). Each rotacap capsule contains less than 1mg of the budesonide steroid - so it is a small dose, but it is delivered directly to the lungs - and somehow seems to be more effective than conventional inhalers even when they are steroids inhalers. It is possible there is something about the powdered steroid delivery method which makes it more effective. CAUTION: if you have yellow/green phlegm then you may have an opportunistic bacterial infection - for which you should take an antibiotics course which should make the phlegm white/clear again - after that if cough still persists you can try the rotacaps method mentioned here. ADDITIONAL PRECAUTION: if you want to avoid the risk of viral persistence (COVID-19) - it may be wise to first do a course of Ivermectin 0.4mg/kg per day for 3 days before starting the rotacaps course. However if Ivermectin is not available, then the rotacaps method still can be tried - and should usually work. NOTE: if rotacaps are not available, and your doctor prescribes a steroids conventional inhaler - and that does not fix the issue - then consider asking him for a rotacaps version, as suggested here.
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Post-COVID-19 residual cough
Post-COVID-19 residual cough - that persists for weeks after an initial COVID-19 infection (even when mild) - is very hard to treat - or is often left untreated.
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Post-COVID-19 cough can sometimes persist even after having taken an (oral) steroids Prednisolone 40mg tapering down over 2 weeks course. And even when you took Ivermectin + Famotidine and the full FLCCC protocol from day1 of symptoms - and NAC - and then a post-day8 steroids course (steroids-at-day8) can still have some persistent cough for some time afterwards.
It can sometimes persist for weeks or more. Which may potentially have negative impact on lung health in the long run.
Even those who have used a steroids based inhaler may sometimes find it ineffective - and the cough remains.
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If you want to ensure that post-COVID-19 cough is reversed. Then you can show this article to your doctor.
The most effective (and always worked in the cases I have seen) solution is inhaled Budesonide (+ Formoterol Fumarate) which are available as rotacaps (powder in capsules that you insert into a plastic inhaler device which punctures the capsule - then you breath it in using the device using several deep inhaling efforts) - see below for videos.
Taken 4-5 times a day for 1 week will reverse the most severe of post-COVID-19 coughs.
It has also worked in some less severe cough cases with 2-3 times a day for 5 days.
In any case the effect will be noticeable as soon as you start using it.
There are some precautions - if you have yellow/green phlegm in which case you may want to take an antibiotics course first (see below).
And if you have access to Ivermectin - then an IVM 0.4mg/kg bodyweight 3 day course (taken with fatty meal and split into morning/evening dose) taken first may be advised, before starting the steroids. If you have access to Ivermectin, then just to be safe - and prevent the remote possibility of steroids exacerbating a viral persistence type situation - then you may want to take the Ivermectin first - before you start the rotacaps treatment below.
If you don't have access to Ivermectin - then you may still try the rotacaps treatment - and it will probably work.
The steroids dose in the rotacaps is less than 1mg of steroids. So it is a small dose - delivered directly to the lungs.
After using the plastic inhaler device (into which the rotacaps capsule is inserted) - you may want to wash out your mouth if you dislike the bitter taste left in the mouth area from the steroids powder inhaled from the rotacap capsule.
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Budesonide rotacaps
For these cases, your physician can try using a Budesonide rotacaps inhaler - usually available as Budesonide + Formoterol Fumarate in rotacaps.
You insert the rotacaps capsule in a rotacaps inhaler plastic device.
And then you inhale deeply a few times until there is no more powder visible in the rotacaps capsule.
Do this 4-5 times a day for a week.
This usually will get rid of post-COVID-19 persistent cough.
I have tried this on many cases - including traditional doctors who mentioned their family members were having this issue.
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Usually doctors and patients may think this cough is a harmless side effect of the recent COVID-19 infection and will reverse on it's own.
That may happen - but if it doesn't, and you are finding that the cough is persisting, then in order to avoid any risk of long term harm to lungs - or fibrosis - it may be wise to try to reverse the cough.
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I have found that Budesonide 400mcg + Formoterol Fumarate 6mcg in rotacaps capsule - taken 4-5 times a day for a week will generally reverse this issue.
I have also seen patients benefit with just 2-3 times a day for 5 days.
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Difficult to treat
While oral steroids - Prednisolone 40mg type of doses for a week - may fix the issue - sometimes patients who have had a full 2 weeks course of steroids (starting at 40mg for example and tapering to zero) - can still have some persisting cough.
(TODO: write substack article on protocol that leads to zero long haulers)
.Since I recommend steroids-at-day8 for all to avoid long haulers - I have had opportunity to see how some traces of persistent cough can remain even in otherwise seemingly recovered cases.
While oral steroids can help - the most effective seems to be the rotacaps method.
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I also suspect that steroids inhalers (non-rotacaps) are often not as useful - i.e. those who tried this method also didn't seem to have effective reversals (though dosage levels may be the reason).
For this reason I am inclined to think there is something about the rotacaps (i.e. powdered form) - which seems to have more reliable benefit every time. And it may have to do with the particles sticking to the lungs - perhaps they have some longer lasting action.
I don't know the reason - but I am just reporting an observation - that rotacaps (perhaps because of the powder form) seem to more reliably reverse the post-COVID-19 cough.
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Practical considerations
Since long haulers (long COVID-19) issues involve inflammation and a tendency to rebound after steroids course is ended (what would be called "viral persistence").
And there is an interplay between inflammation and viral persistence which makes this into a nonlinear problem (feedback loop between the two - inflammation is a catalyst for viral persistence, and viral persistence causes inflammation).
For this reason, for long haulers, it makes sense to first do an Ivermectin 0.4mg/kg for 3 day course - before start steroids. Just in case.
Although, if someone does not have access to Ivermectin, they can still try the rotacaps treatment described above.
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Other than this - the usual precautions should be taken that are taken by long haulers:
- Vitamin D levels should be kept above 50ng/ml - which means Vitamin D3 5000 IU/day or higher is needed - taken along with Vitamin K2 100-200mcg/day (to avoid soft tissue calcification due to high Vitamin D) - and calcium supplements should be avoided when taking Vitamin D higher doses - instead rely on diet for your calcium needs. Calcium supplements are also nowadays seen as increasing risk of cardiovascular disease.
- 30 minutes of exposure to sunlight (if cannot afford the Vitamin D3 supplementation)
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Caution: Yellow or Green phlegm
If you are seeing yellow/green phlegm coming from your lungs in your sputum (spit) - then you may have a bacterial infection - and you should first do an antibiotics course:
- Doxycycline 100mg+100mg first day - then 100mg per day for 4 more days (total 5 days)
- or another antibiotic that your physician recommends
After starting antibiotics, within 1-2 days, the yellow/green phlegm should become white/transparent - however you should still complete the full antibiotics course.
After the phlegm becomes white/clear - and if cough is still persisting - then you can try the rotacaps treatment mentioned above.
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Prices worldwide
The Budesonide 400mcg + Formoterol Fumarate 6mcg (rotacaps) - are usually used with a plastic rotacaps inhaler device - some call it a Turbuhaler, while others call it a Revolizer (depending on region).
A box of 30 rotacaps capsules and the plastic inhaler can cost $5-10 in some developing countries. And are available over the counter (OTC) without requiring a prescription.
In the US and developed countries, this product will usually require a doctor's prescription. And the costs will be more.
This is another example of how layers of middlemen, inflate the eventual cost of pharmaceutical drugs for the patient. Reform in healthcare needs to be done in these countries - where illegal drugs are available more readily than pharmaceutical drugs.
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In the U.S. - 60 rotacaps capsules cost around $45:
https://www.pharmacychecker.com/symbicort+turbuhaler/#prices
Symbicort Turbuhaler Prices - (budesonide/formoterol turbuhaler)
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Availability worldwide
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US, Canada, United Kingdom, Australia, New Zealand:
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https://www.mysymbicort.com/asthma.html
Symbicort Turbuhaler
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SYMBICORT TURBUHALER - budesonide/formoterol fumarate dihydrate dry powder for
oral inhalation
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https://www.medicines.org.uk/emc/product/1327/pil
Symbicort Turbohaler 200/6 Inhalation powder
AstraZeneca UK Limited
>Prescription only medicine
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Symbicort Turbuhaler (budesonide–formoterol) inhaler
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https://www.medsafe.govt.nz/profs/datasheet/s/symbicortinh.pdf
SYMBICORT 200/6 TURBUHALER, inhalation powder
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India:
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https://www.ciplamed.com/product-index/foracort-rotacaps
>FORACORT-400 Rotacaps
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>Each capsule contains:
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>Formoterol fumarate dihydrate IP - 6 mcg
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>Budesonide IP - 400 mcg
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>Dry Powder for Inhalation
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FORMOTEROL FUMARATE AND BUDESONIDE POWER FOR INHALATION(ROTO CAPS), 200 mcg
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https://www.humanbiolife.com/formiprime-200-ROTACAPS
FORMIPRIME-200 ROTACAPS
Composition : Budesonide I.p. 200mcg + Formoterol Fumarate Dihydrate I.p.6mcg Powder for Inhalataion
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Japan:
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https://www.rad-ar.or.jp/siori/english/search/result?n=1692
Symbicort Turbuhaler 60 doses
AstraZeneca K.K
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Phillipines:
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https://www.mims.com/philippines/drug/info/neumoterol?type=full
Neumoterol
>Budesonide 200mcg
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>Formoterol Fumarate (as dihydrate) 6mcg
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Pakistan:
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https://highnoon-labs.com/hi_products/combivair/
>Combivair 400 Rotacap: Each capsule contains:
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>Budesonide 400mcg
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>Formoterol Fumarate (as dihydrate) 6mcg
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How to use rotacaps - videos
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Here are some videos explaining how to use rotacaps and the associated inhaler device:
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https://www.youtube.com/watch?v=Qpe7TLMswOI
How to use a Turbuhaler
Feb 26, 2016
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https://www.youtube.com/watch?v=NAlb_dO2794
How to use a Turbuhaler
Singapore General Hospital
Sep 26, 2014
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https://www.youtube.com/watch?v=qTT06E4mUtU
How to use Symbicort Turbuhaler
Dr. Stefan Cristian Stanel
Sep 25, 2022
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https://www.youtube.com/watch?v=3Txjor3yf2A
How to know Symbicort was inhaled correctly?
Dr. Stefan Cristian Stanel
Jul 31, 2022
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https://www.youtube.com/watch?v=xf9hSKE97GY
How to use Revolizer dry powder inhaler - A guide for Allergy and Asthma patient - Dr Shahid Abbas
Feb 13, 2023
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https://www.youtube.com/watch?v=YhJVHTTqkN8
How to use a Revolizer? (English)
Apr 26, 2024
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https://www.youtube.com/watch?v=d1gvt7Mqvmc
Revolizer how to work.
Oct 9, 2022
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References:
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https://www.webmd.com/drugs/2/drug-148390/budesonide-formoterol-inhalation/details
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https://ec.europa.eu/health/documents/community-register/2016/20160706135330/anx_135330_en.pdf
pg 2:
>Budesonide/Formoterol Teva 160 micrograms / 4.5 micrograms inhalation powder
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>Inhalation powder.
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>White powder.
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>White inhaler with a semi-transparent wine red mouthpiece cover.
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>Budesonide is in a class of medications called steroids. It works by reducing swelling in the airways. Formoterol is in a class of medications called long-acting beta agonists (LABAs). It works by relaxing and opening air passages in the lungs, making it easier to breathe.
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Budesonide and formoterol (inhalation route)
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>US Brand Name
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>Symbicort
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>Symbicort Aerosphere
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>Canadian Brand Name
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>Symbicort 100 Turbuhaler
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>Symbicort 200 Turbuhaler
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>This medicine is available only with your doctor's prescription.
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https://www.mayoclinic.org/drugs-supplements/budesonide-inhalation-route/description/drg-20071233
>When using the Pulmicort Flexhaler:
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>This medicine comes as a powder that you breathe into the lungs with a special inhaler that is placed in the mouth. It is used by adults, teenagers, and children who are 6 years of age and older.
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>When you are finished, place the cover back on the inhaler and twist shut. Rinse your mouth with water and spit out the water. Do not swallow the water. This helps prevent hoarseness, throat irritation, and infections in the mouth.
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