. 2022 Apr 1;21(2):9–20. doi: 10.1007/s11901-021-00581-x

Table 2.

Summary of considerations and international societal guidance regarding management of chronic liver disease during COVID-19 pandemic. AASLD, American Association for the Study of Liver Disease. EASL, European Association for the Study of Liver Diseases. Similar recommendations for these conditions are made by the Asian-Pacific Association of the Study of Liver Diseases (APASL) [61]. AFP, alpha-fetoprotein. AH, alcoholic hepatitis. ALD, alcoholic liver disease. HCV, hepatitis C virus. LT, liver transplantation. NAFLD, non-alcoholic fatty liver disease. MAFLD, metabolic-associated fatty liver disease

Etiology	Considerations	Guidance statements/recommendations
Viral hepatitis	- Initiation and continuation of antiviral treatment - Risk of reactivation of hepatitis B	AASLD[59]: - Initiation of hepatitis B/C treatment in patients without COVID-19 is not contraindicated - Initiation of chronic hepatitis B treatment for patients with COVID-19 is not contraindicated and should be considered particularly when starting immunosuppression
EASLD[60, 62]: - Continue therapy through mailed prescriptions and initiate therapy as recommended by established guidelines
NAFLD/MAFLD	- Risks factors for severe COVID-19 - Lifestyle alterations	AASLD[59]: - Educate patients that they may be at increased risk given metabolic comorbidities
EASL[60, 62]: - Educate patients regarding increased risk of severe COVID-19 with metabolic comorbidities - Continue intensive lifestyle interventions, nutritional guidance, and weight loss advice, treat hypertension per guidelines
ALD	- Reduced psychosocial support - Potential for more severe COVID-19 - Use of steroids, LT	AASLD[59]: - Use steroids with caution in patients with COVID-19 (when potential benefit may outweigh risk)
EASL[60, 62]: - Pre-emptive outreach via telephone with alcohol liaison and cessation services - Educate against disinformation regarding alcohol use reducing COVID-19 risk - Careful use of corticosteroids for severe AH
Hepatocellular carcinoma	- Missed screening/surveillance - Locoregional therapy - Chemotherapy/immunotherapy	AASLD[59]: - Continue monitoring for HCC as close to on-time as possible but an arbitrary delay of 2 months is reasonable, after informed consent - Proceed with treatments or surgical resections when able rather than delaying
EASL[60, 62]: - Multidisciplinary tumor boards should continue to function and provide recommendations - Prioritize patients for screening through published HCC risk stratification tools (including patients with elevated AFP, chronic hepatitis B, HCV-related cirrhosis, or NASH)
Autoimmune liver disease	- Alterations to immunosuppression - Management of flares	AASLD[59]: - Do not make anticipatory adjustments to immunosuppression in patients without COVID-19 - Start immunosuppressive therapy in patients who have strong indications for treatment - Consider reduction in level of immunosuppression in patients with AIH who have COVID-19 (individualized to patient circumstances)
EASL[60, 62]: - Reduction of immunosuppression only under special circumstances (lymphopenia, bacterial/fungal superinfection) - Emphasis on utilization of vaccinations - Addition of or conversion to dexamethasone if hospitalized for COVID-19
Compensated cirrhosis	- Screening for varices - Vaccinations - Nutrition/frailty	AASLD[59]: Consider primary prophylaxis with non-selective beta-blockers with patients with clinically significant portal hypertension or high risk of decompensation - Continue secondary prophylaxis with endoscopy/band ligation
EASL[60, 62]: - Education regarding risks for worsening hepatic decompensation, severe COVID-19 and death - Every effort should be made to resume the guideline-directed care - Test all patients prior to screening endoscopy and in areas of low prevalence, resume screening endoscopy as appropriate

Etiology

Considerations

Guidance statements/recommendations

Viral hepatitis

- Initiation and continuation of antiviral treatment

- Risk of reactivation of hepatitis B

AASLD[59]:

- Initiation of hepatitis B/C treatment in patients without COVID-19 is not contraindicated

- Initiation of chronic hepatitis B treatment for patients with COVID-19 is not contraindicated and should be considered particularly when starting immunosuppression

EASLD[60, 62]:

- Continue therapy through mailed prescriptions and initiate therapy as recommended by established guidelines

NAFLD/MAFLD

- Risks factors for severe COVID-19

- Lifestyle alterations

AASLD[59]:

- Educate patients that they may be at increased risk given metabolic comorbidities

EASL[60, 62]:

- Educate patients regarding increased risk of severe COVID-19 with metabolic comorbidities

- Continue intensive lifestyle interventions, nutritional guidance, and weight loss advice, treat hypertension per guidelines

ALD

- Reduced psychosocial support

- Potential for more severe COVID-19

- Use of steroids, LT

AASLD[59]:

- Use steroids with caution in patients with COVID-19 (when potential benefit may outweigh risk)

EASL[60, 62]:

- Pre-emptive outreach via telephone with alcohol liaison and cessation services

- Educate against disinformation regarding alcohol use reducing COVID-19 risk

- Careful use of corticosteroids for severe AH

Hepatocellular carcinoma

- Missed screening/surveillance

- Locoregional therapy

- Chemotherapy/immunotherapy

AASLD[59]:

- Continue monitoring for HCC as close to on-time as possible but an arbitrary delay of 2 months is reasonable, after informed consent

- Proceed with treatments or surgical resections when able rather than delaying

EASL[60, 62]:

- Multidisciplinary tumor boards should continue to function and provide recommendations

- Prioritize patients for screening through published HCC risk stratification tools (including patients with elevated AFP, chronic hepatitis B, HCV-related cirrhosis, or NASH)

Autoimmune liver disease

- Alterations to immunosuppression

- Management of flares

AASLD[59]:

- Do not make anticipatory adjustments to immunosuppression in patients without COVID-19

- Start immunosuppressive therapy in patients who have strong indications for treatment

- Consider reduction in level of immunosuppression in patients with AIH who have COVID-19 (individualized to patient circumstances)

EASL[60, 62]:

- Reduction of immunosuppression only under special circumstances (lymphopenia, bacterial/fungal superinfection)

- Emphasis on utilization of vaccinations

- Addition of or conversion to dexamethasone if hospitalized for COVID-19

Compensated cirrhosis

- Screening for varices

- Vaccinations

- Nutrition/frailty

AASLD[59]:

Consider primary prophylaxis with non-selective beta-blockers with patients with clinically significant portal hypertension or high risk of decompensation

- Continue secondary prophylaxis with endoscopy/band ligation

EASL[60, 62]:

- Education regarding risks for worsening hepatic decompensation, severe COVID-19 and death

- Every effort should be made to resume the guideline-directed care

- Test all patients prior to screening endoscopy and in areas of low prevalence, resume screening endoscopy as appropriate