EVMS CRITICAL CARE
COVID-19 MANAGEMENT PROTOCOL

Developed and updated by Paul Marik, MD
Chief of Pulmonary and Critical Care Medicine
Eastern Virginia Medical School, Norfolk, VA
November 2nd, 2020

This is our recommended approach to COVID-19 based on the best (and most recent) literature. This is a very dynamic topic; therefore, we will be updating the guideline as new information emerges. Please check on the EVMS website for updated versions of this protocol.
EVMS COVID website: https://www.evms.edu/covid-19/medical_information_resources/
Short url: evms.edu/covidcare

Disclaimer: The information provided in this protocol is primarily to provide information to physicians on a protocol that we found to be highly effective in damping down the hyperinflammatory cytokine “storm” that is the cause of mortality and morbidity in COVID-19. Our guidance should only be used by medical professionals in formulating their approach to COVID19. Patients should always consult with their physician before starting any medical treatment.

Excerpts from EVMS Protocol:

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, 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 supportive evidence indicating the efficacy of these agents. Furthermore, there is emerging data 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, extremely 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. [1-16] 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. [1-16]
• Vitamin C 500 mg BID (twice daily) and Quercetin 250 mg daily. [17-28] Note that prolonged high dose quercetin has very rarely been associated with hypothyroidism. [29,30] Quercetin should be used with caution in patients with hypothyroidism and TSH levels should be monitored.
• Melatonin (slow release): Begin with 0.3mg and increase as tolerated to 2 mg at night. [31-38]
• Zinc 30-50 mg/day (elemental zinc). [17,24,26,27,39-43]
• B complex vitamins [44-48]

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[241]
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. [242]
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