EASL and ESCMID published a position paper to offer regulation for physicians involved in the care of patients with chronic liver disease during the early stages of the coronavirus disease 2019 (COVID-19) pandemic. It has become increasingly apparent that pre-existing liver diseases and liver injury during the disease course should be considered when managing patients with COVID-19.

All patients with chronic liver disease should adhere to common rules of physical distancing. Besides, summary of recommendations for management of liver diseases in patients with COVID-19.

Non-alcoholic fatty liver disease

• Awareness should be spread among patients regarding potential adverse metabolic and hepatic outcomes of social isolation, such as sedentary lifestyles and increased consumption of processed foods. 
• Patients should be encouraged to adopt intensive lifestyle intervention, including nutritional guidance, weight loss advice, and diabetes management in order to prevent progression of liver disease with future SARS-CoV-2 infection. 

Autoimmune liver disease

• The guidelines advises not to reduce immunosuppressive therapy in patients with autoimmune liver disease to prevent SARS-CoV-2 infection. Dosage should be decreased only under special circumstances such as medication-induced lymphopenia, or bacterial/fungal superinfection in cases of severe COVID-19, after consultation with a specialist.
• All patients should receive vaccination for Streptococcus pneumoniae and influenza.

Hepatocellular carcinoma 

• Full HCC surveillance should be continued wherever possible. Patients at increased risk, including those with elevated alpha-fetoprotein levels, advanced cirrhosis, chronic hepatitis B, NASH/diabetes etc. should be prioritised in combination with the use of published HCC risk stratification scores.

Liver transplant recipients 

• The recommendations advise against decreasing the dose of immunosuppressive therapy to prevent SARS-CoV-2 infection. Reduction should only be considered under special conditions, such as medication induced lymphopenia, or bacterial/fungal superinfection in case of severe COVID-19 after consultation with a specialist.
• Clinicians should take consideration of high reported rates of fear and anxiety regarding COVID-19 in liver transplant (LT) recipients and the obstruction this may create to compliance with immunosuppressive medication and attendance at scheduled medical visits. 

Cirrhosis 

• Patients with cirrhosis are mostly susceptible to both the outcome of SARS-CoV-2 infection and to the adverse effects of delayed or altered standard of care during the COVID-19 pandemic. 
• Clinicians should put every effort to continue the best standard of care for patients with cirrhosis according to guidelines.
• Special effort should be made to manage patients with cirrhosis who are admitted for reasons other than COVID-19 in a designated non-COVID-19 ward. 
• Adherence to the guidelines on prophylaxis of spontaneous bacterial peritonitis, gastrointestinal haemorrhage, and hepatic encephalopathy should be done to prevent decompensation and avoid admission is mandatory. Early admission should be done for all patients with cirrhosis who become infected with SARS-CoV-2. 

Alcohol-related liver disease 

• Chronic alcohol consumption may increase an individuals likelihood to acute respiratory distress syndrome secondary to SARS-CoV-2 infection.
• Social isolation can cause new or elevated alcohol consumption; an increase in alcohol related admissions including new hepatic decompensation should be expected during and after periods of physical distancing.
• Clinicians should be conscious of misinformation circulating online regarding the protective effects of alcohol against SARS-CoV-2, resulting in previous cases of deliberate excess consumption.

Viral hepatitis 

• Resume treatment of chronic hepatitis C virus (HCV) and chronic hepatitis B virus (HBV), if already receiving treatment.
• Use telemedicine/local laboratory testing for follow-up visits in patients receiving antiviral therapy, send follow-up prescriptions by mail and provide extended prescription supplies including full courses of direct-acting antiviral medications to complete HCV treatment. 
• Keep working towards the World Health Organization goal of eradicating viral hepatitis by 2030 by trying to acclimatize the cascade-of-care to the new coronavirus situation and make adjustments for safe delivery of services in regard to local requirements.

Source: Boettler T, Marjot T, Newsome PN, et al. Impact of COVID-19 on the care of patients with liver disease: EASL-ESCMID position paper after 6 months of the pandemic. JHEP Rep. 2020 Oct; 2(5): 100169.