Fluvoxamine should only be o ered to patients with COVID-19- who are not yet on supplemental oxygen, and who are within 7 days of symptom onset. *Ideally COVID-19 is proven by PCR or a provider-administered rapid test. Not yet immunized Immunocompromised At least 6 months from last dose of vaccine Age 60+ Age 50+ with at least one comorbidity (e.g., diabetes, cardiovascular disease, obesity, lung disease, kidney disease) Of Indigenous background With developmental disabilities# What Prescribers and Pharmacists Need to Know
Why is fluvoxamine used to treat COVID 19?
The consequences of COVID-19 that lead to poor outcomes, including hospitalization, invasive ventilation, and death, are in large part due to inflammation.
Fluvoxamine is an SSRI (selective serotonin reuptake inhibitor) typically used to treat depression and anxiety. It a ects the sigma-1 receptor that controls inflammation and may reduce inflammation in COVID-19. Fluvoxamine is more anti-inflammatory than other SSRIs (i.e., this is not expected to be a class e ect).

# What is the benefit of fluvoxamine for COVID 19?
Two studies (STOP-COVID 1 1 and the TOGETHER 2 trials) have shown a benefit from treatment with fluvoxamine in adult outpatients with PCR-proven COVID-19 who were less than 7 days from onset of symptoms. The studies suggest fluvoxamine may reduce ER visit length, hospitalization, and disease progression.
Research on fluvoxamine was done before widespread immunization and before the Delta and Omicron variants were circulating. However, with the anticipated impact of surging Omicron cases on the healthcare system, the Ontario Science Advisory Table has made  If the drug is well tolerated, increase the dose to 100 mg PO BID on day 2. If the drug is less well tolerated, consider a dose of 50 mg PO BID on day 2, and increase the dose to 100 mg PO BID on day 3.
If the patient was on another SSRI/SNRI- before switching to fluvoxamine, and they were at or near the maximum dose, increase the dose to 150 mg PO BID.
Continue therapy for a total of 10 to 15 days.

# Sotrivomab
Anti-SARS-CoV-2 neutralizing monoclonal antibodies such as sotrivomab have been shown to benefit patients without immunity to COVID-19 (vaccine or disease-induced) who are within 7 days of symptom onset. 4 The evidence of benefit for sotrivomab in patients with COVID-19 not on supplemental oxygen is more certain than the evidence for fluvoxamine.
Remdesivir is a direct-acting antiviral agent that has been shown to reduce the risk of COVID-19-related hospitalization and death in patients who are within 7 days of symptom onset and have risk factors for disease progression. 5 Remdesivir impacts outcomes that are likely more important to more patients than fluvoxamine (e.g., shorter time to recovery).

# Budesonide Remdesivir
The inhaled corticosteroid budesonide has been shown to shorten duration of symptoms for high risk outpatients with COVID-19. 6 It has not been shown to reduce the risk of hospitalization or other serious outcomes.
Fluvoxamine has many drug interactions. Refer to page 2 Fluvoxamine should not replace outpatient therapies with a higher likelihood of e ect, such as sotrivomab and remdesivir. If patients are eligible for and can access these agents, they should be used preferentially.
What side effects should I be aware of?
Common side e ects of fluvoxamine are generally mild and can include nausea, constipation, diarrhea, dry mouth, insomnia, agitation, somnolence, nervousness, headache, and dizziness. Rare, but serious side e ects include serotonin syndrome/toxicity and QT prolongation.
Serotonin syndrome is a rare, but serious complication of SSRIs, particularly when the maximum dose is exceeded or when used with other serotonergic drugs.
The risk of QT prolongation is rare and a baseline ECG is not recommended in otherwise healthy patients with no risk factors. Fluvoxamine should be avoided in patients with a history of congenital long QT syndrome or who take medications with significant potential for QT prolongation.
Fluvoxamine should be o ered preferentially to patients at higher risk of severe disease or complications from COVID-19, including those:

# Who should receive fluvoxamine?
What drug interactions should I consider before prescribing fluvoxamine? *For a full list of drug interactions, visit: / product-pdf/luvox-pm-2017-06-15.pdf?la=en-ca  Non-steroidal anti-inflammatory drugs Fluvoxamine is contraindicated in patients taking: MAO (monoamine oxidase) inhibitors Thioridazine and mesoridazine Pimozide Terfenadine, astemizole, and cisapride Tizadine Fluvoxamine should be used with caution in patients taking any of the following drugs:- Fluvoxamine should not be used in combination with clopidogrel as it may reduce the anti-platelet e ect of clopidogrel (CYP2C19 interaction). Ca eine: Fluvoxamine raises serum concentrations of ca eine up to 5-fold. Patients should avoid ca eine as much as possible while taking fluvoxamine. Drugs a ecting bleeding risk: ASA, warfarin, and NSAIDs  . Specific benzodiazepines: triazolam, midazolam, alprazolam, and diazepam. Drugs a ecting seizure threshold: e.g., select antidepressants, mefloquine, and tramadol. CYP1A2 Substrates: e.g., amitriptyline, clomipramine, clozapine, quetiapine, and olanzapine. CYP2C19 Substrates: e.g., diazepam, phenytoin, warfarin, lansoprazole, and omeprazole. CYP2C9 Substrates: e.g., valproate. CYP3A4 Substrates: e.g., alprazolam, diltiazem, carbamazepine, methadone, cyclosporine, and sildenafil. Others: propranolol and ropinirole.

# What if my patient is already taking psychiatric drugs?
If patient is taking MAO inhibitors: Do NOT give fluvoxamine due to risk of serotonin syndrome.
If patient is taking non-sertraline SSRI/SNRI: Switch to fluvoxamine for 10 to 15 days, then switch back OR if there are concerns that switching could be detrimental due to discontinuation side e ects or negative impact on psychiatric condition, fluvoxamine can be added if the original drug is at low dose (i.e., half of maximum recommended dose).
If patient is taking sertraline: Switch to fluvoxamine. Do NOT add it on, as sertraline can counteract some of fluvoxamine's anti-inflammatory actions.
Use caution if prescribing fluvoxamine to patients with a history of bipolar disorder or mania, as it can trigger a manic or hypomanic episode.
At this time, there is no evidence to support the use of other SSRI/SNRIs for the treatment of COVID-19 because they do not have the same degree of anti-inflammatory activity.