the impact of covid-19 on cirrhosis...
TRANSCRIPT
![Page 1: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/1.jpg)
@ebtapper
The Impact of COVID-19 on Cirrhosis CareElliot Tapper MDAssistant Professor of MedicineUniversity of [email protected]
![Page 2: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/2.jpg)
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
![Page 3: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/3.jpg)
Division of Gastroenterology & Hepatology
Outline
Impact on the liver
Impact on people with cirrhosis
Managing cirrhosis
![Page 4: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/4.jpg)
High* AST is Common
Sultan and Altyar Gastro AGA rapid review May 2020
![Page 5: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/5.jpg)
Magnitude of Elevation Not High
Bhangash et al Lancet Gastroenterol Hepatol March 2020
![Page 6: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/6.jpg)
Liver Tests As Risk Biomarker
Lei et al Hepatology May 2020
AST
Bilirubin
ALT
ALP
![Page 7: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/7.jpg)
Timing Tells The Story
7Lei et al Hepatology May 2020
![Page 8: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/8.jpg)
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
![Page 9: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/9.jpg)
Characteristics of Hospitalized Adults With COVID-19 in an Integrated Health Care System in California
9Myers et al JAMA 2020
![Page 10: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/10.jpg)
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
![Page 11: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/11.jpg)
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
![Page 12: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/12.jpg)
12
![Page 13: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/13.jpg)
The Impact of COVID-19 Unfolds in 3 Waves:1st Wave of the COVID-19 Pandemic
Tapper and Asrani J Hep April 2020
![Page 14: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/14.jpg)
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
![Page 15: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/15.jpg)
UNOS Transplant
15
UNOS May 10 2020
![Page 16: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/16.jpg)
The Impact of COVID-19 Unfolds in 3 Waves:2nd Wave of the COVID-19 Pandemic
Tapper and Asrani J Hep April 2020
![Page 17: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/17.jpg)
Hepatic Encephalopathy Hospital Volume
Rebound?
Source: University of Michigan
![Page 18: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/18.jpg)
The Impact of COVID-19 Unfolds in 3 Waves:3rd Wave of the COVID-19 Pandemic
Tapper and Asrani J Hep April 2020
![Page 19: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/19.jpg)
Seizing Opportunity:Adaptations to Preserve High Quality Care
Tapper and Asrani J Hep April 2020
![Page 20: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/20.jpg)
New Ways for Old Goals
20
![Page 21: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/21.jpg)
Rapid Increase in Telemedicine
Forbes et al Gastro April 2020
![Page 22: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/22.jpg)
2222
COVID visitkinetics
Phreesia data, Mehrotra, Commonwealth Fund
Proportion telemed visits
![Page 23: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/23.jpg)
23
Is our use ultrasounda threat to telemed?
![Page 24: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/24.jpg)
24
Who needs HCC
screening?
Why dothey come to
clinic?
![Page 25: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/25.jpg)
25
![Page 26: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/26.jpg)
26
Two thingsTrack
Accommodate
![Page 27: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/27.jpg)
27
![Page 28: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/28.jpg)
Telehealth And Survival In Cirrhosis: Rural And Underserved
Su et al Hepatology 2018
![Page 29: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/29.jpg)
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
![Page 30: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/30.jpg)
30
![Page 31: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/31.jpg)
31
![Page 32: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/32.jpg)
Development of Quality Measures in Cirrhosis
32Kanwal et al. Hepatology. 2019;69(4):1787-1797
![Page 33: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/33.jpg)
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)
![Page 34: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/34.jpg)
34
Proactive > Reactive
![Page 35: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/35.jpg)
35
At-risk population
![Page 36: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/36.jpg)
β Blockers to Prevent Decompensation of Cirrhosis in Patients With Clinically Significant Portal Hypertension
36Villanueva et al. (2019)
![Page 37: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/37.jpg)
37
![Page 38: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/38.jpg)
Acceptance And Use of A Smartphone Application In Cirrhosis
38
12%
Louissaint et al. (2020)
Jeremy Louissaint, MD
![Page 39: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/39.jpg)
39Campagna. Hepatology. 2017
The Animal Naming Test: An Easy Tool For the Assessment of Hepatic Encephalopathy
![Page 40: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/40.jpg)
Improving Care in Outpatients With Cirrhosis and Ascites: A New Model of Care Coordination by Hepatologists
Morando F, J Hepatol 2013;
![Page 41: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/41.jpg)
Care Management Program Improves 1-Year Survival After Admission For Cirrhosis and Ascites
Morando F, J Hepatol 2013;
![Page 42: The Impact of COVID-19 on Cirrhosis Careempireliverfoundation.org/wp...of-COVID19-on-cirrhosis-6-14-20...16-… · Impact onthe liver Impact onpeople with cirrhosis Managingcirrhosis](https://reader035.vdocuments.net/reader035/viewer/2022081611/5f0a8d297e708231d42c30c3/html5/thumbnails/42.jpg)
42
Collaboration
Expansion
Pro-action