@ebtapper

The Impact of COVID-19 on Cirrhosis CareElliot Tapper MDAssistant Professor of MedicineUniversity of Michiganetapper@umich.edu

Division of Gastroenterology & Hepatology

Disclosures

This presenter has the following declarations of relationship with industry:• NIH K23 research grant• Grants to Michigan: Gilead, Valeant• Ad boards: Rebiotix, Mallinckrodt, Bausch• Consulting: Allergan, Axcella, Novartis, Novo Nordisk

Division of Gastroenterology & Hepatology

Outline

Impact on the liver

Impact on people with cirrhosis

Managing cirrhosis

High* AST is Common

Sultan and Altyar Gastro AGA rapid review May 2020

Magnitude of Elevation Not High

Bhangash et al Lancet Gastroenterol Hepatol March 2020

Liver Tests As Risk Biomarker

Lei et al Hepatology May 2020

AST

Bilirubin

ALT

ALP

Timing Tells The Story

7Lei et al Hepatology May 2020

Autopsy Findings/Venous Thromboembolism in Patients With COVID-19

Autopsy says:

8

Case Autopsy findings1 Hepatomegaly2 Shock3 Shock4 Shock5 Normal6 Normal7 Normal8 Chronic congestion9 Fatty change10 Normal11 Normal12 Chronic congestion

Wichmann et al Annals May 2020

Characteristics of Hospitalized Adults With COVID-19 in an Integrated Health Care System in California

9Myers et al JAMA 2020

Medical History of Patients with Confirmed COVID-19, UK

UK Intensive Care National Audit and Research Center (ICNARC)

ICU utilization

Compare:Viral pneumonia2017-2019

10ICNARC 2020

Clinical Characteristics and Outcomes of COVID-19 Among Patients with Pre-Existing Liver Disease in United States

TriNETXLiver disease“matched”

11Singh and Khan Gastro April 2020

12

The Impact of COVID-19 Unfolds in 3 Waves:1st Wave of the COVID-19 Pandemic

Tapper and Asrani J Hep April 2020

Declining Cirrhosis Hospitalizations in the Wake of the COVID-19 Pandemic: A National Cohort Study

14Mahmud N et al Gastro May 2020

VA data

Cirrhosis admissions

UNOS Transplant

15

UNOS May 10 2020

The Impact of COVID-19 Unfolds in 3 Waves:2nd Wave of the COVID-19 Pandemic

Tapper and Asrani J Hep April 2020

Hepatic Encephalopathy Hospital Volume

Rebound?

Source: University of Michigan

The Impact of COVID-19 Unfolds in 3 Waves:3rd Wave of the COVID-19 Pandemic

Tapper and Asrani J Hep April 2020

Seizing Opportunity:Adaptations to Preserve High Quality Care

Tapper and Asrani J Hep April 2020

New Ways for Old Goals

20

Rapid Increase in Telemedicine

Forbes et al Gastro April 2020

2222

COVID visitkinetics

Phreesia data, Mehrotra, Commonwealth Fund

Proportion telemed visits

23

Is our use ultrasounda threat to telemed?

24

Who needs HCC

screening?

Why dothey come to

clinic?

25

26

Two thingsTrack

Accommodate

27

Telehealth And Survival In Cirrhosis: Rural And Underserved

Su et al Hepatology 2018

Cirrhosis is Special:Optimal Outcomes Take a Village

Total 30-day readmissions afte

r any hospitalizatio

n during

follow up

P-valu

e

IRR and 95% CI

Total 30-day readmissions afte

r any hospitalizatio

n during

follow up

P-valu

e

IRR and 95% CI

Continuity of care

Usual

provider of

careLowest

25th percentil

e

ref ref

Lowest

25th percentil

e

ref ref

25th-

50th percentil

e

1.18 (1.05

, 1.33)

25th-

50th percentil

e

1.04 (0.91

, 1.19)

50th-

75th percentil

e

1.14 (1.01

, 1.28)

50th-

75th percentil

e

1.11 (1.00

, 1.23)

Highest

25th percentil

e

1.19 (1.06

, 1.34)

Highest

25th percentil

e

1.12 (1.00

, 1.25)

29

30

31

Development of Quality Measures in Cirrhosis

32Kanwal et al. Hepatology. 2019;69(4):1787-1797

Screening Questions And Treatment Options For Common Disabling Symptoms In Cirrhosis

Sample Question(s) Therapeutic OptionsHow often during the last two weeks have you had muscle cramps?

• Normalize electrolytes and fluid balance• Taurine (3 grams daily)• Vitamin E (300 mg three times a day)• Baclofen (5–10 mg three times a day as needed)

How much of the time have you been troubled by itching during the last two weeks?

• Moisturizing cream for dry skin• Cholestyramine (4 grams daily)• Naltrexone (50 mg daily)• Sertraline (75–100 mg daily)• Ursodeoxycholic acid (13–15 mg/kg/day in 2 doses)

Have you had difficulty sleeping at night?Have you felt sleepy during the day?

• Optimize treatment for HE• Optimize sleep hygiene• Referral to sleep specialist to assess for sleep apnea• Mindfulness training• Melatonin (3–5 mg daily)

Have you had any sexual activity in the past few weeks? How satisfied were you with your sexual function during the past few weeks?

• Phosphodiesterase inhibitors (e.g. sildenafil 25–100 mg as needed)

• Sex therapy referral• Referral to Urology 33Thomson et al. (2018)

34

Proactive > Reactive

35

At-risk population

β Blockers to Prevent Decompensation of Cirrhosis in Patients With Clinically Significant Portal Hypertension

36Villanueva et al. (2019)

37

Acceptance And Use of A Smartphone Application In Cirrhosis

38

12%

Louissaint et al. (2020)

Jeremy Louissaint, MD

39Campagna. Hepatology. 2017

The Animal Naming Test: An Easy Tool For the Assessment of Hepatic Encephalopathy

Improving Care in Outpatients With Cirrhosis and Ascites: A New Model of Care Coordination by Hepatologists

Morando F, J Hepatol 2013;

Care Management Program Improves 1-Year Survival After Admission For Cirrhosis and Ascites

Morando F, J Hepatol 2013;

42

Collaboration

Expansion

Pro-action

The End

@ebtapper

Elliot Tapper MDAssistant Professor of MedicineUniversity of Michiganetapper@umich.edu