Managing Autoimmune Liver Diseases During COVID-19 Pandemic
Explore insights on managing autoimmune liver diseases like autoimmune hepatitis during the COVID-19 pandemic, including diagnosis strategies, treatment considerations for immunosuppressed patients, and guidance for cholestatic liver diseases. Learn how to handle cases of AIH patients contracting COVID-19, address the impact on cholestatic liver conditions, and navigate the complexities of patient care amidst the pandemic.
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LIVER CO-MORBIDITIES AND COVID-19 Management of Autoimmune Liver Management of Autoimmune Liver Disease During COVID Disease During COVID- -19 19 Kelly W. Burak, MD, FRCPC, MSc (Epid) Professor, Departments of Medicine & Oncology University of Calgary, Calgary, AB, Canada
Autoimmune Hepatitis Diagnosis during pandemic Best to avoid liver biopsy during pandemic -> empiric therapy1 Do NOT assume elevated ALT is a disease flare without biopsy2 Immunosuppressed patients may be at higher risk of infection2,3 Symptomatic patient should have priority for testing Do NOT reduce immunosuppression in an attempt to reduce risk 1. Lleo A, J Hepatol 2020; 2. Fix OK, Hepatology 2020; 3. Boettler T, J Hepatol 2020.
Are immunosuppressed patient at increased risk for more severe COVID-19? 7162 confirmed cases in USA4 6% hospitalized and 9% ICU patients were on immunosuppression Does NOT appear that immunosuppressed patients are at increased risk of more severe pulmonary disease (ARDS)5 ICU patients may get cytokine storm (similar to HLH) High ferritin, increased IL-6 Corticosteroids NOT recommended as they may exacerbate lung injury6 4. MMWR Morb Mortal Wkly Rep. 2020;69:382-6; 5. D'Antiga L, Liver Transpl. 2020; 6. Mehta P, Lancet 2020.
What if an AIH patient gets COVID-19? Avoid high doses of prednisone2,3 Lower the dose of corticosteroids May need stress doses in ICU to avoid adrenal insufficiency SARS-CoV-2 may cause lymphopenia2 If fever or worsening respiratory status may need to lower dose of azathioprine or mycophenolate 2.Fix OK, Hepatology 2020; 3. Boettler T, J Hepatol 2020.
Cholestatic Liver Diseases Impact of COVID-19 is not clear (7) PBC patients Should continue therapy (e.g. UDCA, OCA, bezafibrate) Cirrhotics can delay HCC surveillance Non-selective beta-blockers preferred to endoscopy for varices (8) PSC patients Use MRI/MRCP only if likely to change management Fever / worse liver tests should NOT be assumed to be COVID-19 Obtain blood cultures, IV antibiotics +/- ERCP 7. Zhang C, Lancet Gastroenterol Hepatol 2020; 8. Congly SE, Can Liver J 2020 (in press).
