@ebtapper
The Impact of COVID-19 on Cirrhosis CareElliot Tapper MDAssistant Professor of MedicineUniversity of [email protected]
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