Dear Colleagues,

Given continued rise in COVID cases, we recognize the need for vigilance against COVID and welcomed the announcement yesterday that family physicians can now prescribe Paxlovid and it will be dispensed in community pharmacies – which gives us an important additional tool to care for our patients.

The OCFP has been working to inform policy for Paxlovid prescribing so that we can ensure the process is smooth and you feel confident prescribing. We are aware that you will need to quickly become familiar with prescribing a new medication that has multiple drug interactions. At the same time, it is clear that the participation of family doctors is crucial to help ensure an equitable and accessible rollout of Paxlovid to our patients.

To help you, we have highlighted key details below and we will continue to work to get the updates and resources you need.

Prescribing Paxlovid

Information for Patients

• Factsheet for patients (from Ontario Health)
• Adaptable OCFP script for your practice
• Online treatment screener from the Ministry of Health, for patients to self-assess their eligibility.
• When assessed and recommended for treatment, there is no cost to any Ontario patient and a Health Card is not required.

Tools and Resources for Family Doctors

• Paxlovid (nirmatrelvir and ritonavir) should be prescribed to patients with mild to moderate disease who are at high-risk of hospitalization and death. It should be prescribed within 5 days of symptom onset. Evidence in this NEJM article.
• See Ontario Health’s Paxlovid information for primary care for details, including how to assess and prescribe, or if needed, direct your patient for assessment at a clinical assessment centre dispensing Paxlovid so they can receive treatment if indicated.
• For an excellent summary, Paxlovid: What Prescribers and Pharmacists Need to Know, from the Science Advisory Table (SAT), and for your patients, this patient information sheet from University Health Network.
• The CEP has published Paxlovid guidance for primary care.
• Patient testing: a positive COVID-19 test is required to receive treatment – through a rapid antigen test (RAT), rapid molecular or PCR test. At-home rapid antigen test with provider verification (e.g. in-person, photo or video) is acceptable.
• Molecular testing (PCR) is now available to any patient for whom you are considering treatment, including symptomatic people aged 70 or older and all who are immunocompromised, to support eligibility for treatment. See updated testing guidance.
• Eligible patients: for all available treatments, see treatment guideline summary from the Science Advisory Table (SAT)and once again this University of Waterloo FAQs Treatment Options for Mild COVID-19.
  • Note that SAT guidance, which is based on the available data, differs from the MOH eligibility criteria. Use your clinical judgement or seek advice to consider use for patients who do not strictly meet SAT criteria. We recognize that, at this time, our knowledge and experience is evolving with increasing use of this medication worldwide, and we will continue to keep you updated on the evidence as it emerges.
• Prescribing info: drug-drug interactions, particularly with the ritonavir component of Paxlovid, are a significant and common challenge. We recommend you consider seeking the community pharmacist’s support to help assess/manage patients’ medications.

 Along with the prescription, sharing an updated list of medications and medical conditions, and recent renal function measures (if available) would help facilitate communication and shared work. For checking drug interactions: 

• Paxlovid: What Prescribers and Pharmacists Need to Know
• Download University of Liverpool’s COVID-19 Drug Interactions Checker 
• Here is a list of pharmacies dispensing Paxlovid. (list available from April 13)

Paxlovid will be the focus in our next COVID-19 Community of Practice session with UofT DFCM, Friday April 22 at 7:55 a.m. We’ll be joined by Dr. Kelly Grindrod, Pharmacist and Associate Professor, University of Waterloo School of Pharmacy, Dr. Andrew Morris, Medical Director, Antimicrobial Stewardship Program, Sinai Health System/University Health Network, and others. 

Register now

Other treatment-related information

• Remdesivir, an intravenous antiviral medication, may be available for high-risk people who cannot take Paxlovid. It is available at eight treatment clinics across the province. Contact your local Clinical Assessment Centre for how to access for outpatients.
• The monoclonal antibody Sotrovimab is no longer recommended for treating COVID-19, based on evidence of limited effectiveness against Omicron BA.2 subvariant.
• Fluvoxamine and budesonide remain treatment options for mildly ill patients at higher risk of severe illness. (see page 2 of the SAT guideline and Fluvoxamine: What Prescribers and Pharmacists Need to Know.)
• A reminder that some high-risk patients who can be managed at home may be referred to a remote care management program. Community availability and eligibility criteria vary. And for remotely monitoring your COVID patients at home, you can still order O² saturation monitorsthrough Ontario Health.
• Evusheld, a preventive treatment for high-risk individuals who cannot receive a COVID-19 vaccine, has yet to be approved, and is still under review by Health Canada.

Vaccines

• Ontario has expanded eligibility for fourth doses to include people 60 and older, as well as First Nations, Inuit and Métis individuals and their non-Indigenous household members aged 18 and older. The recommended interval is five months from the previous dose. The evidence at this point shows the benefit of the fourth dose is for those who are most immunocompromised; for now, healthcare workers in general are not eligible. For a discussion of second boosters, see the April 8 COVID-19 CoP session with infectious disease physician Dr. Isaac Bogoch.
• Please continue to support patients to complete their primary series and/or receive their third doses – many eligible have still not received these.
• More information on accessing Novavax is anticipated. The vaccine is authorized for those 18 years of age and older, and is available through referral to your local PHU for those unable or unwilling to receive mRNA vaccines.
• The pediatric Moderna vaccine has been approved by Health Canada for use in children six to 11.
• OMA has published a new tool for primary care, Pathways to COVID-19 Vaccination for Patients 5+ with Allergies.

IPAC | PPE

• We were pleased to hear from the Chief Medical Officer of Health that masking is likely to continue in high-risk settings, including community practices, beyond the stated deadline of April 27, and we will continue to advocate for universal masking in our clinics. Here is printable poster to remind patients to keep mask on while in the office.
• These FAQs from Public Health Ontarioaddress common IPAC questions. Register to attend this PHO webinar, in partnership with the Primary Care Collaborative, on April 14, 12-1 p.m., focused specifically on IPAC in clinical office settings. 

On this Match Day, I am thinking of all fourth-year medical students – no matter what today brought, please be proud of your accomplishments and know that your hard work is valued. We hope to welcome many of you into family medicine. We know that family medicine forms the foundation of all high performing health systems!

At the OCFP, we are working hard to ensure the critical issues facing family physicians are on patients’ minds and the agenda of each party’s policy platform for the June provincial election. If you haven’t already, please check out and join our campaign #LifeWithoutADoctor, and help us spread the word.

Finally, recruitment for the OCFP’s Board of Directors is underway – a terrific opportunity for a meaningful leadership role. The deadline for nominations has been extended to April 28, 2022.

Liz