AASLD Consensus Statement Advises on Liver Disease Treatment During the COVID-19 Pandemic
Key findings
- Patients who have cirrhosis or hepatocellular carcinoma (HCC) or are on immunosuppressant therapy are thought to be at increased risk of severe COVID-19, and there should be a low threshold for SARS-CoV-2 testing if they report COVID-19 symptoms
- In patients with COVID-19, initiating treatment of pre-existing hepatitis B should be considered if there is clinical suspicion of a flare or a need for immunosuppressive therapy. However, initiating treatment of hepatitis C can generally be deferred until recovery from COVID-19
- In patients with HCC (whether on or off therapy) and those at risk of HCC, continue monitoring as close to schedule as circumstances allow, although an arbitrary delay of two months is reasonable
- Patients with known or suspected COVID-19 who are using ACE inhibitors or angiotensin II receptor blockers should continue on them
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As the COVID-19 pandemic continues, hepatologists and liver transplant care providers are faced with an extraordinary amount of rapidly emerging data. To succinctly review what is known about the disease and provide advice about best practices, the American Association for the Study of Liver Diseases has created an expert panel consensus statement that is being regularly updated online.
Raymond Chung, MD, vice chief of the Gastrointestinal Division and director of the Hepatology and Liver Center at Massachusetts General Hospital, was the senior author of the original version of the consensus statement and remains on the working group responsible for the document. The following summary of selected recommendations refers to the update on June 4, 2020.
Evaluation of COVID-19 Patients
Patients who have cirrhosis or hepatocellular carcinoma (HCC) or are on immunosuppressant therapy are thought to be at increased risk for severe COVID-19, and there should be a low threshold for SARS-CoV-2 testing if they report COVID-19 symptoms.
When assessing patients with COVID-19 who have elevated liver biochemistries, COVID-19 itself can be explanatory, but consider etiologies unrelated to COVID-19, including drug-induced liver injury and hepatitis A, B and C.
In patients with autoimmune hepatitis or who have undergone liver transplantation who have active COVID-19 and elevated liver biochemistries, do not presume disease flare or acute cellular rejection without biopsy confirmation.
In children with COVID-19 and elevated aminotransferases, evaluate for underlying liver disease and coexisting infection, because COVID-19 in children is not commonly associated with abnormal liver biochemistries.
Protocols for Outpatients with Hepatitis and/or HCC
Clinicians should continue treatment for hepatitis B and hepatitis C in patients with COVID-19. The document recommends:
- In patients with COVID 19, initiating treatment of pre-existing hepatitis B should be considered if there is clinical suspicion of a flare or a need for immunosuppressant therapy. However, initiating treatment of hepatitis C can generally be deferred until recovery from COVID-19
- In patients with HCC (whether on or off therapy) and those at risk of HCC, continue monitoring as close to schedule as circumstances allow during the pandemic, although an arbitrary delay of two months is reasonable
Discuss with the patient the risks and benefits of delayed surveillance and document the discussion; these patients should be prioritized for imaging studies when feasible.
Proceed with liver cancer treatments or surgical resection when able rather than delaying them due to the pandemic.
Medications for Known or Suspected COVID-19 Patients
Patients receiving ACE inhibitors and angiotensin II receptor blockers should remain on them. Acetaminophen ≤2 g/day is the preferred analgesic and antipyretic. Nonsteroidal anti-inflammatory drugs may be used or continued as needed
The consensus statement addresses numerous other topics, including:
- Management of patients with decompensated cirrhosis and those on the liver transplant waiting list during the pandemic
- Management of post-liver-transplant patients and others on immunosuppressive agents
- Management of inpatients who have COVID-19 and concurrent liver disease
- Investigational COVID-19 therapies
- When to perform endoscopy
The document is not a systematic evidence review and is not intended as a practice guideline. The aim is to help hospitals and clinics develop their own policies to mitigate the impact of COVID-19 on patients with liver disease and health care providers.
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