Treatment of patients with COVID-19

Drugs and biologics are available to treat patients with COVID-19, including antivirals

Antiviral treatment options for adults with COVID-19

According to Ontario Health guidance, antiviral COVID-19 treatments in Ontario should be strongly considered for individuals with COVID-19 symptoms and a positive SARS-CoV-2 test (PCR, rapid molecular or rapid antigen) who are at high risk for severe outcomes from COVID-19.

High-risk individuals who are recommended to receive antiviral therapy are:

Aged 65+
Aged 18+ who are immunocompromised

Antiviral therapy may be considered for high-risk individuals who are:

Aged 18+ with one or more medical condition(s) or health-related social need(s) that put them at higher risk of disease progression
- Refer to Ontario Health’s recommendations for antiviral therapy for adults with mild to moderate COVID-19 to help identify patients at higher risk for disease progression based on the number of conditions they are experiencing
- Individuals with solid organ transplants who test positive for COVID-19 should contact their transplant care team for COVID-19 treatment and follow-up care
Aged 18+ who never received a COVID-19 vaccine

Individuals who are at a higher risk of poor outcomes from COVID-19 based on social determinants of health should also be considered priority populations for access to COVID-19 antiviral therapies. These include individuals aged 18+ who:

Are members of First Nations, Inuit, Métis and urban Indigenous communities, Black communities or other racialized communities
Have an intellectual, developmental or cognitive disability
Use substances regularly (e.g. alcohol)
Live with mental health conditions
Are underhoused

Treatment planning for high-risk patients

Discuss treatment options with high-risk patients and care partners to determine eligibility for COVID-19 therapies and to help develop a treatment plan before any potential infection, so patients can access treatment as quickly as possible when needed.

Treatment plans should include:

Patient goals for care
Where patients can get tested
Signs and symptoms of COVID-19 and when testing and medical care are needed
Healthcare provider contacts for evaluation and treatment following a positive test
Up-to-date renal function tests and other relevant workups (e.g. eGFR, ALT)
Up-to-date medication history, including vitamins, minerals and supplements
Proactive assessment of drug-drug interactions to determine mitigation strategies or alternate therapies that may be needed
How to access COVID-19 therapies locally, including drug funding options

You may choose to contact high-risk patients proactively to provide them with information on antiviral therapies so that they are prepared if they develop COVID-19 symptoms. You can do so during appointments, via email or phone, on your practice’s website or online portal, through community partners or through broader electronic communications to all patients where feasible.

You can also proactively put a COVID-19 antiviral prescription on file for your patient at their local pharmacy. Patients will require a positive test to fill the prescription.

Respiratory Illness Support Line

Physicians can get evidence-based information about respiratory illness therapeutics, including eligibility, access, managing potential drug interactions and navigating specific clinical scenarios, through the Ontario Pharmacists Association’s Respiratory Illness Support Line. This free service, available by phone at 1-888-519-6069, is staffed by registered pharmacists from 10 a.m. to 6 p.m. ET daily and has a chatbot to answer questions after hours. The service is funded by an unrestricted quality improvement grant from Pfizer.

Paxlovid is the preferred first-line therapy when safe and feasible for mild to moderate COVID-19 in patients at high risk of severe disease. Paxlovid is an oral antiviral medication composed of two drugs: nirmatrelvir (which stops viral replication) and ritonavir (which slows the metabolism of nirmatrelvir). It is a five-day course of pills that can be taken at home. It has been demonstrated to reduce the risk of hospitalization in those who are at high risk.

Paxlovid must be started within five days of symptom onset, where the first day of symptoms is day 0.

Physicians who are not comfortable with prescribing Paxlovid can refer eligible patients to the closest participating pharmacy for treatment.

Testing

Patients who are at high risk for severe disease must have a confirmed diagnosis of COVID-19 to be eligible for treatment with Paxlovid. Diagnosis can be confirmed by:

Lab-based PCR
Rapid molecular test (e.g., ID NOW)
Rapid antigen test, administered by the patient or health-care provider (note that a negative rapid antigen test does not rule out COVID-19)

A positive rapid antigen test done at home and verified by the prescriber (in-person, virtual, picture or video) is acceptable.

If you do not have the ability to test the patient in your practice:

Patients eligible for PCR or rapid molecular testings can access testing through participating pharmacies, select primary care settings and hospitals
You can order a publicly-funded PCR test for eligible patients using the Public Health Ontario COVID-19 and Respiratory Virus Test requisition

Access a list of testing locations.

As a reminder, free rapid tests are available through the PPE supply portal for use in your practice, once you are enrolled in the Provincial Antigen Screening Program (PASP). You can enrol in PASP through the Ontario Together Portal. If you do not have an existing account, email sco.supplies@ontario.ca to get set up. Both rapid antigen tests and rapid molecular tests are available. Rapid antigen tests may also be available through public health units and participating health sector partners (e.g., pharmacies, hospitals and other health-care providers).

Prescribing

A prescription for Paxlovid should include the following:

Dosing
Confirmed COVID-19 (PCR or RAT+)
Symptomatic for five days or less (symptom onset is considered day 0)
Increased risk for COVID-19 infection progression
Note on renal function or eGFR (if known)
List of current medications (if known)
Appropriate Limited Use (LU) code

You can prescribe Paxlovid to patients for dispensing at a community pharmacy. Some pharmacists in the community can also prescribe and/or dispense Paxlovid to patients. You also have the option to put a Paxlovid prescription on file for your patient at their local pharmacy. Note that the patients will require a positive test to fill the prescription.

Renal and hepatic impairment

The standard dosing of Paxlovid should be adjusted for those with eGFR 30 to 59 ml/min. The low dose of Paxlovid is suggested for those with eGFR < 30.

Paxlovid is not recommended for those with severe hepatic impairment (Child-Pugh Class C).

Read the Ontario Renal Network’s COVID-19 supplemental clinical guidance on Paxlovid use in patients with advanced chronic kidney disease and patients on dialysis with COVID-19.

Drug interactions

Paxlovid interacts with many medications.

Consult with specialists or other providers as needed to determine drug interactions(s) that can be safely mitigated. Pharmacists will be checking for drug interactions at the point of dispensing. You can also get information on drug interactions by calling the Ontario Pharmacists Association’s Respiratory Illness Support Line toll-free at 1-888-519-6069.

Dispensing and funding options

Paxlovid is available through participating community pharmacies, and they are encouraged to keep a supply of Paxlovid on hand. Should they not have Paxlovid in stock, pharmacists are encouraged to help patients find a pharmacy that does so as part of their ethical obligation to ensure continuity of patient care.

The cost of Paxlovid was covered by the federal government from 2022 to May 2024 as a temporary, extraordinary measure. Funding options now include selected government drug benefit programs, private insurance or direct payment by the patient, consistent with funding models for other medications.

Paxlovid is now covered by the Ontario Drug Benefit (ODB) as a LU benefit for the treatment of mild to moderate COVID-19 for adults who are:

65 years of age and older
Immunocompromised; and/or
18 to 64 years of age with one or more risk factors for severe COVID-19

These patients must have a positive COVID-19 test (PCR or rapid antigen test) and symptoms within the past five days.

If patients do not qualify for Paxlovid through the ODB Formulary, they can seek coverage through the Trillium Drug Program. Eligible Ontario patients who are covered by OHIP can apply if they do not have private insurance or insurance does not cover the full cost.

First Nations, Inuit, Métis and urban Indigenous people who live in Ontario may be eligible for this program as well as the Non-insured Health Benefit (NIHB). The LU criteria under the NIHB is similar to that of the ODB, but includes individuals 60 years of age and older.

If patients are not eligible for coverage through drug benefits programs, they can seek coverage through their private insurance where applicable. If private insurance does not provide full or partial coverage, patients will need to pay for Paxlovid out of pocket. They can contact their local pharmacy for a price estimate.

Refer to Ontario Health released recommendations on remdesivir (Veklury) in adults.

Remdesivir, an intravenous antiviral medication administered as a three-day course, may also be available for patients at high risk of severe COVID-19 who cannot take Paxlovid or are beyond Paxlovid’s treatment window (greater than five days). Community- and hospital-based physicians can refer patients to their local Home and Community Care Support Services (HCCSS) branch to receive Remdesivir in the HCCSS clinic or their home. Appropriate referral forms and supporting documents must be completed and submitted to the local HCCSS branch. This is free of charge for patients with OHIP numbers. If patients do not have OHIP coverage, arrange for them to go to a local hospital or emergency department, or community nursing clinic directly, noting that there may be a cost to patients.

Find out how to access Remdesivir. You can also contact your Ontario Health regional contact for information on accessing Remdesivir.

Ontario Health Regional contacts for COVID-19 antiviral treatments: