EASL updates guidance on COVID-19 in liver disease patients

The European Association for the Study of the Liver (EASL) and European Society of Clinical Microbiology and Infectious Diseases (ESCMID) have updated their guidance on chronic liver disease and COVID-19, issued in March 2020, to reflect emerging evidence.

They stress that people with chronic liver disease are not at increased risk of COVID-19, but if they develop COVID-19, some people with liver disease may have a more severe illness.

People with metabolic-associated fatty liver disease, also known as non-alcoholic fatty liver disease, appear to have more severe COVID-19 and this is correlated with the presence of non-invasive fibrosis. However, EASL and ESCMID say that larger analyses are needed to be certain that metabolic-associated fatty liver disease leads to worse COVIOD-19 outcomes.

No strong evidence has emerged to show that viral hepatitis is associated with worse COVID-19 outcomes.

EASL and ESCMID say that people with cirrhosis are particularly vulnerable if they become infected with SARS-CoV-2. They have a higher risk of death than people without cirrhosis if they develop COVID-19 illness and should be admitted to hospital sooner than other COVID-19 patients.

However, it is not clear if people with cirrhosis who develop COVID-19 are at significantly higher risk of acute liver failure or death compared to people with cirrhosis without COVID-19 who suffer decompensation.

People with cirrhosis who are admitted to hospital with liver failure or decompensation should be tested for SARS-CoV-2 as soon as possible.

Corticosteroid treatment for autoimmune hepatitis does not increase the risk of SARS-CoV-2 infection. Although there is some evidence to show that people taking corticosteroids for autoimmune hepatitis may have more severe COVID-19 illness, more evidence is needed and EASL and ESCMID do not recommend any change in corticosteroid dose unless a patient develop lymphopenia or a fungal or bacterial lung infection as a result of COVID-19.

In cases where people with COVID-19 develop an autoimmune hepatitis flare, EASL and ESCMID encourage doctors to consider using budenoside to treat the flare, to limit total glucocorticoid exposure in circumstances where dexamethasone is given as respiratory support during COVID-19 treatment.

Liver transplant services should be restored as soon as possible, as people with decompensated cirrhosis on the transplant waiting list are at higher risk of death due to COVID-19. Candidates should strictly isolate prior to admission and be screened for possible symptoms or contacts. Candidates should be made aware that SARS-CoV-2 infection in patients undergoing major surgery is associated with an increased risk of severe COVID-19 outcomes. Stringent infection control measures throughout the care pathway are essential.

Immunosuppressive medication should not be discontinued or reduced except in cases of lymphopenia or fungal or bacterial infection. Doctors should discuss with patients the need to maintain immunosuppressive medication, as patients with high anxiety regrading COVID-19 may choose to avoid taking immunosuppressive drugs in the belief that this will reduce their risk of infection.

In liver transplant patients who do develop COVID-19, calcineurin inhibitor and mTOR inhibitor levels should be monitored if any medication is used to treat COVID-19, especially HIV protease inhibitors, hydroxychloroquine or new trial drugs.

EASL and ESCMID also highlight the emerging evidence on blood clots (venous thromboembolism) in people with chronic liver disease and COVID-19. Both chronic liver disease and COVID-19 increase the risk of blood clots. The position paper recommends the use of anticoagulants in people with cirrhosis and portal hypertension, with low molecular weight heparin as standard-of-care preventive treatment in any patient with cirrhosis admitted to hospital, but EASL and ESCMID say more evidence is needed about the potential benefits of routine anticoagulant treatment for anyone with cirrhosis and COVID-19.