Important information regarding changes to coverage and recommendations for COVID-19 treatment in the community.

To: All physicians, primary care providers
Category: Physician Services; Primary Health Care Services
Written by: Health Programs and Delivery Division
Date issued: May 17, 2024
Bulletin Number: 240504

Updated recommendations from Ontario Health

Ontario Health’s Infectious Diseases Advisory Committee has released updated Recommendations for Antiviral Therapy for Adults with Mild to Moderate COVID-19 (April 2, 2024) based on the latest Public Health guidance.

The recommendations are intended to provide guidance for prescribers on antiviral therapy (nirmatrelvir/ritonavir and remdesivir) for adults with mild to moderate COVID-19 in the context of the Omicron subvariants and pre-existing immunity from prior infection or vaccination. Highlights include updates to COVID-19 severity classification and risk factors associated with more severe COVID-19 outcomes, along with an overview of the real-world evidence for antiviral therapies.

For patients who have symptoms of mild to moderate COVID-19 and a positive COVID-19 test, risk factors associated with more severe COVID-19 outcomes where antiviral therapy is recommended include:

  • Adults 65 years of age and older, regardless of vaccination status, with no other risk factors
  • Adults 18 years of age and older who are immunocompromised, regardless of vaccine status or prior COVID-19 infections. Selected examples include:
    • advanced untreated human immunodeficiency virus (HIV) or treated HIV with a CD4 count equal or less than 200/mm3 or CD4 fraction equal or less than 15%
    • active hematological malignancy or recently received treatment for hematological malignancy (example: have received treatment with any anti-CD20 agents or B-cell depleting agents in the last 2 years)
    • chimeric antigen receptor (CAR) T-cell therapy in the last 6 months
    • solid organ transplant, bone marrow transplant or stem cell transplant
    • treatment for cancer (including solid tumors), limited to: systemic therapy in the last 6 months (examples: chemotherapy, molecular therapy, immunotherapy, targeted therapies, monoclonal antibodies, excluding those receiving adjunctive hormonal therapy only) or radiation therapy in the last 3 months
    • prednisone use equal to or greater than 20 mg/day (or corticosteroid equivalent) for 14 days or more, or other moderately or severely immunosuppressive therapies (example: alkylating agents)
    • primary immunodeficiencies (example: hypogammaglobulinemia)

Antiviral therapy may be considered for adults with at least 1 risk factor associated with more severe COVID-19 outcomes, such as:

  • never vaccinated against COVID-19
  • certain underlying medical conditions or social vulnerabilities

A greater number of risk factors are associated with a higher risk of severe COVID-19 outcomes. Please note, the risk of progression to severe COVID-19 depends on the quantity of underlying medical conditions and how controlled the medical conditions are.

For assistance in determining risk level and details about risk factors, medical conditions and social vulnerabilities, please refer to Ontario Health’s Recommendations for Antiviral Therapy for Adults with Mild to Moderate COVID-19.

Access to Paxlovid in the community

Universal access to Paxlovid™ was introduced in 2022 as a temporary, extraordinary measure during the COVID-19 pandemic. The remaining provincial stock of Paxlovid will expire on May 31, 2024.

Effective May 17th, 2024, Paxlovid™ will be publicly-funded for Ontario Drug Benefit (ODB)-eligible individuals (including OHIP+ and Trillium Drug Benefit) who meet the Limited Use (LU) clinical criteria.  The LU criteria will be available on the ODB Formulary as of May 17th.

Once the provincial stock of Paxlovid expires, access for non-Ontario Drug Benefit-eligible Ontarians will adhere to regular process for access to therapeutic drugs. Prescribers and health care providers can check that the patient qualifies for the ODB program. Patients may apply for the Trillium Drug Program (TDP) if they do not qualify under another ODB program. Eligible people who live in Ontario with Ontario Health Insurance Plan (OHIP) can apply for the TDP if they do not have private insurance or their private insurance does not cover 100% of their prescription drug costs. For more information about the program and eligibility, see the TDP webpage.

Nirmatrelvir/ritonavir (Paxlovid™) can continue to be prescribed by physicians, nurse practitioners, and pharmacists, and can be dispensed at community pharmacy locations. The first dose should be started within five days of symptom onset.

Consultation with a pharmacist is recommended to mitigate any potentially significant drug-drug interactions (including natural health products). To guide identification and appropriate management of potential drug-drug interactions, please see the guidance document “Nirmatrelvir/ritonavir (Paxlovid™): What prescribers and pharmacists need to know” for more information.

Access to Remdesivir in the community

At this time, Remdesivir (Veklury™) will remain available through Home and Community Care Support Services and long-term care homes, at no cost to patients with OHIP coverage for whom nirmatrelvir/ritonavir is contraindicated (example: drug-drug interaction that cannot be safely managed, medical contraindication) or when patients are beyond the treatment window for nirmatrelvir/ritonavir initiation (such as symptom onset greater than five days).

Remdesivir (Veklury™) is administered as an IV infusion on three consecutive days for non-hospitalized patients. The first dose should be administered within seven days of symptom onset.

Remdesivir (Veklury™) can be prescribed by physicians and nurse practitioners. Prescribers in hospitals or in the community can refer a patient to their local Home and Community Care Support Services (HCCSS) branch for a nurse to administer remdesivir infusions. Prescribers must complete a referral/prescription form along with the IV referral form and submit them to their local HCCSS branch. A HCCSS care coordinator will follow up with the patient.

Testing – including rapid antigen tests

To initiate treatment, patients must have tested positive for COVID-19. A rapid antigen test (self-administered or provider-administered), a polymerase chain reaction (PCR) test, or a rapid molecular test are all acceptable testing options.

Please note that a negative rapid antigen test does not rule out the possibility of a COVID-19 diagnosis.

PCR testing is available at participating pharmacies for individuals who are considered at higher risk for severe COVID-19 outcomes. Additionally, primary care providers may order publicly-funded PCR testing for eligible patients using the Public Health Ontario COVID-19 and Respiratory Virus Test Requisition form. For help filling out the form use these instructions.

Free rapid antigen tests continue to be available to order via Supply Ontario’s PPE Supply Portal. The distribution of rapid antigen tests to patients is voluntary and will not be reimbursable by the Government of Ontario (no billing codes). For assistance in creating an account or accessing an existing account, or for any questions about orders and shipment, please contact sco.supplies@supplyontario.ca.

Questions or more information

For questions or more information, please email Ontario Public Drug Programs.

For additional resources visit Ontario Health COVID-19 Treatment webpage. 

Keywords/Tags

COVID-19 antiviral treatment; Paxlovid; nirmatrelvir/ritonavir; remdesivir; Veklury; COVID-19

Contact information

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