Table 4.

Management of liver disease in COVID-19

	Investigations		Pharmacological management	Nonpharmacological management	Recommendations
	Laboratory and other biochemistry	Imaging and biopsy
No preexisting liver disease	LFTs on admission (baseline) and at least twice weekly during hospital stay 100 Screen for HBV if systemic immunosuppression and tocilizumab has been given for > 7 days 73	Indicated only in suspicion of vascular or biliary disease 96, 97 Limited/no place for liver biopsy 102	In moderate to severe liver injury lopinavir-ritonavir, tocilizumab are contraindicated 102	N/A	Baseline LFTs should be performed on admission to identify preexisting liver disease Transient elevation in LFTs may be seen and needs monitoring at least twice weekly in patients receiving hepatotoxic medication
Preexisting liver disease (NAFLD, cirrhosis, HCC, chronic Hepatitis B, alcoholic liver disease)	LFTs on admission (baseline) and at least every other day during hospital stay 103	Indicated only in suspicion of vascular or biliary disease 101 Limited/no place for liver biopsy 102	Concomitant administration of tenofovir derivatives with lopinavir-ritonavir—> increases tenofovir concentrations 104 Caution in use of Paxlovid (combination of Ritonavir + Nirmatrelvir) in preexisting liver disease, liver enzyme abnormality or liver inflammation 110 Paxlovid may induce hepatic enzymes and breakdown of nirmatrelvir or ritonavir 110 Paracetamol > 2 g per day to be avoided 104 NSAIDs used with caution 104 Corticosteroids used with caution in hepatitis B as they may increase the risk of hepatitis in chronic HBV 104 Continue treatment of HBV even during treatment of COVID-19, discontinuation of antiviral treatment of hepatitis B discouraged 105 Anti-HBV drugs may be considered when patients are on immunosuppressive treatment with careful monitoring 105	Strict measures to minimize exposure to COVID-19 especially in HCC due to very high risk of hospital-acquired COVID-19. 98 COVID-19 vaccines as early as possible 109 Treat HCC without delay. 98 Pneumococcal and influenza vaccines irrespective of the age. 99	Apart from HCV without decompensated cirrhosis, all other preexiting liver diseases should be managed as before. Use of immunosuppression in chronic liver disease requires caution and close monitoring. HCC should be treated without delay taking all precautions.
Liver transplant	Test donor and recipient for COVID-19 preoperatively	No specific recommendations	Remdesivir—risk of hepatotoxicity Increased levels with liver enzyme inducers 108 Tocilizumab—minor interaction with cyclosporine, tacrolimus, and sirolimus May reduce concentrations of calcineurin inhibitors. Use with chloroquine and hydroxychloroquine may produce additive toxicity. Myelosuppressive effect may potentiate hematological toxicity of ribavirin and interferon-beta. 102	Liver transplantation should not be postponed during pandemic 106 COVID-19 vaccines as early as possible 109	Although challenging, LT should not be postponed due to COVID-19 Early COVID-19 vaccination with third booster dose 1–2 months after second dose Perform baseline LFT before starting remdesivir therapy and monitor during therapy. Discontinue infusions if ALT and AST > 10 times ULN.

ALT = alanine aminotransferase; AST = aspartate aminotransferase; HBV = hepatitis B virus; HCC = hepatocellular carcinoma; HCV = hepatitis C virus; LFT = liver function test; LT = liver transplant; NAFLD = nonalcoholic fatty liver disease; NSAIDs = nonsteroidal anti-inflammatory drugs; ULN = upper limit of normal.