What Are the Roles of a Hepatologist in the Management of a Patient With COVID‐19?
Elevation of serum transaminase levels is commonly observed in patients with COVID‐19, and a hepatologist might therefore be consulted. All of the guidance suggests that the underlying cause of liver injury may be related to SARS‐CoV‐2 infections, exacerbation of preexisting CLD, or drug‐induced hepatotoxicity. AASLD and APASL provide an algorithm to clinical evaluations (Fig. 1). A key question is whether patients with CLD have a higher risk for severe COVID‐19. AASLD and APASL suggest nonalcoholic fatty liver disease (NAFLD) as an independent prognostic factor, and patients with CLD should be prioritized as candidates for COVID‐19 drug trials. EASL and AASLD mention that patients with NAFLD are more likely than others to have other comorbidity risks for severe COVID‐19. To date, there is no evidence that patients with stable CLD due to chronic hepatitis B (CHB) or chronic hepatitis C (CHC) have increased susceptibility to SARS‐CoV‐2 infection. It is controversial whether there is an increased risk for flare‐up of CHB or CHC during COVID‐19 and whether prophylactic therapy should be started. Both AASLD and APASL recommend continuing treatment for CHB or CHC in patients with COVID‐19. APASL recommends prophylactic hepatitis B therapy for those planned for anti‐IL‐6 or other immunosuppressive therapy. Initiating prophylactic hepatitis C therapy is not recommended. If there is any suggestion of a flare‐up, therapy should be initiated in patients who are not already receiving hepatitis B or hepatitis C treatment.
Fig 1  Approach to the patient with COVID‐19 and elevated serum liver biochemistries. Reproduced with permission from Hepatology. 5  Copyright 2020, American Association for the Study of Liver Diseases. On May 1, 2020, remdesivir, a nucleotide RNA polymerase inhibitor, was authorized by the US Food and Drug Administration under Emergency Use Authorization for treatment of those patients hospitalized with severe COVID‐19. 9  APASL and AASLD recommend close monitoring of liver function in patients, especially those with CLD, who are treated with remdesivir. Patients with decompensated CLD and those with alanine aminotransferase (ALT) >5 times upper limit of normal should not be treated with remdesivir.