Guidance on Managing Liver Dysfunction During COVID-19 Pandemic

By Reuters Staff

July 09, 2020

NEW YORK (Reuters Health) - Patients with COVID-19 may develop abnormal liver function and it's important to consider the potential impact of COVID-19 on the liver, especially in the Asia-Pacific region where chronic liver diseases are prevalent, say the authors of a position statement.

The statement, from the Asia-Pacific Working Group for Liver Derangement during the COVID-19 Pandemic, provides 36 recommendations covering the use of drug therapy for COVID-19 in the case of liver dysfunction, and assessment and management of patients with chronic hepatitis B or hepatitis C, non-alcoholic fatty liver disease, liver cirrhosis, and liver transplantation.

Among the group's advice:

- Test liver function in hospitalized patients with COVID-19. While the optimal interval for liver tests is unclear, it's reasonable to monitor liver tests twice weekly in patients on potentially hepatotoxic medication, patients with pre-existing liver disease, and more frequently in any patients with abnormal liver function.

- Closely monitor patients with abnormal liver function when using off-label lopinavir-ritonavir, chloroquine, hydroxychloroquine, and tocilizumab.

- Withhold off-label treatment for COVID-19 in the case of moderate-to-severe (category 2-3) liver injury.

- Perform standard investigations for liver diseases in patients with COVID-19 and persistent liver derangement; the type of investigations will depend on the clinical presentation and pattern of liver injury but should involve at least serological tests for viral hepatitis.

- Start antiviral therapy according to the existing international guidelines for HBV newly diagnosed at the time of presentation with COVID-19.

- Do not stop oral nucleoside antiviral therapy for HBV at the time of COVID-19 to avoid the risk of HBV reactivation and clinical flare.

- Concomitant use of protease inhibitor-containing direct-acting antiviral (DAA) regimens for hepatitis C virus with lopinavir-ritonavir is contraindicated.

- Continue DAAs if being taken at the time of COVID-19 diagnosis, unless drug-drug interactions would be problematic or patients are in critical condition.

- Defer DAAs until after COVID-19 if clinically significant drug-drug interactions with COVID-19 therapies are present.

- Drug-drug interactions between some new COVID-19 therapies and DAAs should be closely monitored as data are scarce.

- Have heightened awareness of adverse clinical outcomes in patients with non-alcoholic fatty liver disease (NAFLD) who have COVID-19, especially when diabetes is present.

- Postponement of elective upper gastrointestinal endoscopic examination for variceal screening in patients with no history of gastrointestinal bleeding until a COVID-19 outbreak is under control is reasonable, and might be necessary if COVID-19 outbreaks are ongoing in the region.

- Non-invasive tools (e.g., Baveno VI criteria, platelet-to-liver stiffness measurement ratio, liver and spleen stiffness measurement) might be used to identify patients who are at high risk of having clinically significant varices. Endoscopic eradication of esophageal varices should be done after a variceal bleed.

- In the case that emergency or urgent upper endoscopy is warranted in suspected or confirmed cases of COVID-19, it should be done under a negative-pressure room when available with strict isolation precautions, and all endoscopy personnel should wear appropriate personal protective equipment, including N95 respirator and waterproof protective gown.

The full position statement is published in Lancet Gastroenterology and Hepatology.

The writing group says more data are needed to understand the impact of COVID-19 on the liver and how best to manage patients with liver diseases.

Corresponding author Dr. Henry Lik-Yuen Chan from The Chinese University of Hong Kong did not respond to a request for comment by press time.

SOURCE: https://bit.ly/2BPiGzn Lancet Gastroenterology, online June 22, 2020.

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