Recommendations apply to patients >18 years of age. Recommendations are based on the best available data and may change as additional data becomes available. Science Briefs can be found on the Ontario COVID-19 Science Advisory Table website.Dexamethasone 6 mg PO/IV daily for 10 days (or until discharge if sooner) is recommended.n Reassurance and information for self-monitoring of symptoms (including self-monitoring of oxygen saturation) are recommended. p Fluvoxamine 50 mg PO daily titrated up to 100 mg PO twice daily for a total of 15 days may be considered for these patients if they present within 7 days of symptom onset. See fluvoxamine recommendation statement for higher risk mildly ill patients. p Budesonide 800 mcg inhaled twice daily for 14 days may be considered for these patients. See budesonide recommendation statement for higher risk mildly ill patients. g The following therapies are not recommended for these patients: nirmatrelvir/ritonavir (Paxlovid) and remdesivir. u There is currently insufficient evidence to make a recommendation around aspirin or anticoagulation for mildly ill patients. g The following therapies are not recommended for mildly ill patients: dexamethasone, tocilizumab, sarilumab, and baricitinib.# 
Tocilizumab is recommended for patients who are on recommended doses of dexamethasone therapy (or a dose-equivalent corticosteroid) AND are within 14 days of hospital admission (or within 14 days of a new COVID-19 diagnosis if the infection was nosocomially acquired).

# RECOMMENDATIONS FOR DRUG SHORTAGE SITUATIONS
In drug shortage situations, a single dose of tocilizumab 400 mg IV or sarilumab 400 mg IV should be used for all eligible patients. A second dose of tocilizumab or sarilumab should not be given to any patient.
Baricitinib 4 mg PO/NG daily for 14 days (or until discharge if sooner) is recommended in patients who are on recommended doses of dexamethasone therapy (or a dose-equivalent corticosteroid) or who have a contraindication to corticosteroid treatment. The panel does not recommend combined use of baricitinib and IL-6 inhibitors due to absence of safety and efficacy evidence.
Dexamethasone 12 mg PO/IV daily for 10 days (or until discharge if sooner) may be considered in patients who are unable to receive IL-6 inhibitors (tocilizumab, sarilumab) or baricitinib. This recommendation is based on very low certainty evidence of reduction in days alive without life support, and the need for inpatient treatment options with a reasonable safety profile during an anticipated spike in COVID-19 cases due to the Omicron variant and widespread shortages of IL-6 inhibitors and baricitinib.
Prophylactic dose low molecular weight or unfractionated heparin is recommended. These patients should not receive therapeutic dose anticoagulation unless they have a separate indication for this treatment.
Remdesivir is not recommended for patients receiving mechanical ventilation. Remdesivir 200 mg IV on day 1, then 100 mg IV daily for 4 days may be considered in patients requiring high-flow oxygen (i.e., oxygen by mask, oxygen by high-flow nasal cannula, or non-invasive mechanical ventilation).

# SARS-CoV-2 neutralizing antibodies are not recommended.
Nirmatrelvir/ritonavir (Paxlovid) is not recommended.
Bacterial co-infection is uncommon in COVID-19 pneumonia at presentation. Do not add empiric antibiotics for bacterial pneumonia unless bacterial infection is strongly suspected. Continue empiric antibiotics for no more than 5 days, and de-escalate on the basis of microbiology results and clinical judgment.
n g g p g g g n n
Tocilizumab is recommended for patients who have evidence of systemic inflammation, defined as a serum CRP of 75 mg/L or higher, AND have evidence of disease progression (i.e., increasing oxygen or ventilatory requirements) despite 24-48 hours of recommended doses of dexamethasone therapy (or a dose-equivalent corticosteroid), AND are within 14 days of hospital admission (or within 14 days of a new COVID-19 diagnosis if the infection was nosocomially acquired).

# RECOMMENDATIONS FOR DRUG SHORTAGE SITUATIONS
In drug shortage situations, a single dose of tocilizumab 400 mg IV or sarilumab 400 mg IV should be used for all eligible patients. A second dose of tocilizumab or sarilumab should not be given to any patient. Baricitinib 4 mg PO/NG daily for 14 days (or until discharge if sooner) is recommended in patients who are on recommended doses of dexamethasone therapy (or a dose-equivalent corticosteroid) or who have a contraindication to corticosteroid treatment. The panel does not recommend combined use of baricitinib and IL-6 inhibitors due to absence of safety and efficacy evidence.
Dexamethasone 6 mg PO/IV daily for 10 days (or until discharge if sooner) is recommended. If patients are discharged with home-based oxygen therapy, dexamethasone 6 mg PO daily until oxygen is no longer required (for a maximum of 10 days) may be considered.
Remdesivir 200 mg IV on day 1, then 100 mg IV daily for 4 days is recommended.
Therapeutic dose anticoagulation may be considered over prophylactic dose anticoagulation in patients who are felt to be at low risk of bleeding. All other patients should receive prophylactic dose anticoagulation.  STEP 1 u Determine the risk of disease progression.

# SARS-CoV
- Higher risk individuals are those who have a 5% risk of hospitalization if they develop COVID-19. Standard risk individuals are those who have a <5% of hospitalization.
- Indigenous people, Black people, and members of other racialized communities may be at increased risk of disease progression due to disparate rates of comorbidity, increased barriers to vaccination, and social determinants of health. They should be considered priority populations for access to COVID-19 drugs and therapeutics. 

# AGE (years)
NUMBER

# STEP 2 u
Based on the risk level, refer to the corresponding recommendation statements below.

# RISK LEVEL RECOMMENDATIONS HIGHER RISK OF SEVERE DISEASE
Individuals who have a 5% risk of hospitalization or are immunocompromised u It is recommended that higher risk patients receive nirmatrelvir/ritonavir (Paxlovid) or remdesivir. The choice of drug depends on availability, contraindications, and ease of administration.

# These individuals should have a reasonable expectation for 1-year survival prior to SARS-CoV-2 infection.
n Nirmatrelvir/ritonavir (Paxlovid) at a dose of 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet), with all three tablets taken together orally twice daily for 5 days, is recommended for these patients if they present within 5 days of symptom onset.
- In patients with moderate renal impairment (eGFR 30 to <60 mL/min), the dose should be reduced to 150 mg nirmatrelvir (one 150 mg tablet) and 100 mg ritonavir (one 100 mg tablet) taken together twice daily for 5 days. Paxlovid is not recommended in patients with severe renal impairment (eGFR <30 mL/min). - Specialized pharmacist consultation is important to mitigate any significant drug-drug interactions with other drugs. - Paxlovid should be preferentially deployed in regions and to populations where administration is a barrier to intravenous medication.
n Remdesivir 200 mg IV on day 1, then 100 mg IV daily for 2 days is recommended for these patients if they present within 7 days of symptom onset.
u If the above drugs are unavailable or contraindicated: p Fluvoxamine may be considered for patients with mild COVID-19 illness presenting within 7 days of symptom onset. The recommended starting dose is 50 mg PO daily, titrated up to 100 mg PO twice daily for a total of 15 days. Pharmacist consultation and outpatient provider follow-up is important to avoid any significant adverse drug interactions with fluvoxamine. This recommendation balances the very low certainty evidence of benefit for preventing hospitalization with the need for management options for mild illness with a reasonable safety profile during a surge in COVID-19 cases due to the Omicron variant.
p Budesonide 800 mcg inhaled twice daily for 14 days may be considered for these patients. This recommendation is based on very low certainty evidence of reduction in duration of symptoms, and the need for outpatient treatment options with a reasonable safety profile during an anticipated spike in COVID-19 cases due to the Omicron variant. Budesonide may have a role as an additional therapy in patients already on other therapies who have respiratory symptoms.

# STANDARD RISK