This document was developed by Ontario Health's COVID-19 Therapeutics Interim Working Group based on best available evidence and expert consensus. There are limitations to the evidence that is currently available. Prescribers must determine whether adopting suggested information is clinically appropriate for individual patients through a risk-benefit assessment.# Background
During the COVID-19 pandemic in Ontario, the Ontario COVID-19 Science Advisory Table prepared and maintained guidance on the therapeutic management of adult patients with COVID-19. Health care providers have used this guidance, along with criteria from the Ministry of Health, to determine which patients would benefit from receiving nirmatrelvir/ritonavir (Paxlovid) to prevent severe illness due to COVID-19. As of fall 2022, the Ontario COVID-19 Science Advisory Table has been dissolved, and their guidance on the therapeutic management of COVID-19 will no longer be updated.
In fall 2022, Ontario Health established a COVID-19 Therapeutics Interim Working Group (Appendix A) to provide guidance and advice to Ontario Health and the Ministry of Health on priority issues regarding the appropriate use of therapeutics for COVID-19 infection. The first priority issue to be addressed by the Working Group relates to updating the recommendations on which patients would benefit from receiving nirmatrelvir/ritonavir (Paxlovid).
The following consensus-based recommendation was informed by a primary literature review and jurisdictional scan (Appendix B). Prescribers must determine whether adopting suggested information is clinically appropriate for individual patients through a risk-benefit assessment.

# Recommendation
Paxlovid should be strongly considered for individuals who have a confirmed COVID-19 diagnosis (based on positive PCR, rapid molecular, or rapid antigen test result), present within 5 days of symptom onset, and meet one or more of the following criteria:
- The individual is 60 years of age or older;
- The individual is 18 years of age or older and is immunocompromised;
- The individual is 18-59 years old and is at higher risk of severe COVID-19. Patients at higher risk of severe COVID-19 include:
- Those who have one or more comorbidity that puts them at higher risk of severe COVID-19 disease OR
- Those with inadequate immunity, i.e.:
- Unvaccinated or incomplete primary series OR o Completed primary series AND last COVID-19 vaccine dose was more than 6 months ago AND last SARS-CoV-2 infection was more than 6 months ago Social determinants of health may confer an increased risk of disease progression. Individuals who are at a higher risk of poor outcomes from COVID-19 infection based on social determinants of health should be considered priority populations for access to Paxlovid. Individuals at higher risk include Indigenous people, Black people, other members of racialized communities, individuals with intellectual, developmental, or cognitive disability, people who use substances regularly (e.g. alcohol), people who live with mental health conditions, and people who are underhoused.
Note: Combinations of risk factors are associated with higher risk of severe COVID-19.

# Additional resources
Visit the Ontario Health COVID-19 treatment website for the latest resources on Paxlovid and other COVID-19 therapeutics.

# Appendix B: References
The following resources informed these recommendations: