Q&A with Dr. Tamar Taddei for Liver Disease Patients about COVID-19
Dr. Tamar Taddei received her medical doctorate from Georgetown University where she stayed to complete her Internal Medicine Residency and Chief Residency. She completed her gastroenterology/hepatology training at Yale University. She is an Associate Professor in the Department of Medicine, Section of Digestive Diseases. Her clinical interests include general and transplant hepatology; her clinical and research focus is on liver cancer. She directs the Liver Cancer Program at VA Connecticut Healthcare System and co-directs the VA Connecticut Health Care System Patient Safety Center of Inquiry in Cancer Care Coordination. She directs outcome and quality improvement projects and collaborates on clinical trials and translational research projects aimed at improving the detection, treatment and multidisciplinary management of patients with hepatocellular carcinoma. Dr. Taddei has been recognized with teaching awards for her commitment and dedication to the education of medical students, residents, and fellows. She is an Associate Director of the Medical Scientist Training Program at Yale. Dr. Taddei is a member of the American Liver Foundation’s National Medical Advisory Committee and is the Co-Chair of the Executive Committee.
As COVID-19 began to spread in the United States, Dr. Taddei provided us a very comprehensive webinar which can be watched here. Dr. Taddei committed a large portion of that webinar to answering questions from our community. We have included those questions and her answers, below, to help you learn more about what COVID-19 means for people impacted by liver disease and their loved ones.
If you have had a transplant, you should not take non-steroidal anti-inflammatory drugs (NSAIDs), like ibuprofen or naproxen (Advil, Motrin, or Aleve), as they can interact with your anti-rejection medications. Some health care professionals have argued against taking NSAIDs during COVID-19 as they may worsen the disease.
It’s a misconception that people with liver disease can’t take acetaminophen. Acetaminophen (Tylenol) is perfectly fine to take, even if you have very advanced liver disease, but you should not exceed two grams (or 2,000 milligrams [mg]) in a 24-hour period. That amounts to two extra strength tablets (500 mg each) twice a day or two regular strength tablets (325 mg each) three times a day.
People with PBC should be diligent in maintaining social distancing. Some retail or grocery stores have started putting marks on the floor where people should stand which is helpful, but anytime you need to go out, be sure you are six feet from other people. Disinfect high-traffic surfaces in your home, wash your hands for 20 seconds, and follow the other precautions suggested for the general public. If you become symptomatic, you should call your provider. Do not ignore symptoms.
Wearing a mask helps prevent you from touching your face and keeps sneezes and coughs contained. The CDC recommendations now suggest wearing a cloth mask. Handwashing is very important because we know that COVID-19 tends to persist on surfaces for days. Gloves may help cut down on exposure when going through high traffic areas, like the grocery store, where many people may be touching surfaces (such as door handles).
You don’t need to do anything extra, but you need to be diligent about carefully disinfecting high traffic areas, washing your hands, and social distancing.
Everyone should be trying to avoid bringing illness home. Partners of people with underlying risks, like cirrhosis, should be just as diligent as their partner when it comes to distancing. Consider wearing gloves and a mask when you are out, particularly when you can’t keep 6’ distance. When you get home, try not to touch anything or anyone until you have showered and changed your clothes.
If you are an essential worker, you need to be very careful about what you might be bringing home. For example, if you’re on the front lines, in healthcare, and you have a loved one that is 65 or older or has cirrhosis or another major underlying condition, consider asking for housing separate from your loved one while you’re actively engaging with patients and for a period of time afterward for quarantine.
There are reports of COVID-19 causing acute (or short term) liver injury. This is a transient (temporary, passing) enzyme elevation. Elevated enzymes reflect acute inflammation and improve as symptoms improve.
It is possible. A lot of viruses, even common cold viruses, like adenoviruses, can directly affect the liver but only briefly. Hepatitis B and Hepatitis C replicate and take up residence in the liver where viruses like COVID-19 and adenovirus may use the liver briefly as a place to replicate. We do not expect any lasting liver damage from COVID-19.
We worry about people with cirrhosis because the immune system is affected by cirrhosis. The sicker you are with cirrhosis, the less likely your body will be able to handle another illness. If you are ill with end stage liver disease (decompensated cirrhosis), with a high MELD score, any added illness may precipitate liver failure.
I have seen cases in people post liver transplant and patients were asymptomatic. This is something we need to understand better. There are more and more reports coming out that people who are post-transplant may have mild to no symptoms, which is why we’re curious about whether patients who are on immune suppressants may fare better with the virus; it’s an important hypothesis to examine.
We do know that people who develop the severe respiratory symptoms of COVID-19, with adult respiratory distress syndrome, demonstrate a very enthusiastic immune response. What that means is that your own immune system gets triggered and what follows is something called a cytokine release. In a cytokine release a lot of chemicals are released in the body which cause overwhelming inflammation; in this case, inflammation in the lungs. People who have had transplants have a suppressed immune system. The hypothesis is that perhaps those individuals can’t mount the cytokine release that leads to overwhelming inflammation. This requires further study.
We don’t know for sure yet, but the available evidence suggests infected people who survive develop protective antibodies. We don’t know if that immunity will persist as this virus develops mutations, as all viruses are prone to do.
COVID-19 may become like the flu. Every year, predictions are made about which strain of the flu is going to be most common that season and the vaccine is designed based on that research. Every year, you need a flu shot, because every year, the flu is slightly different or mutated. If you get the flu this year, you’ll only get it once, and wouldn’t get it again in the same season.
Currently, we think if you get COVID-19 in a particular season you are immune to it. But, if it has significant mutations or changes in the next season, you may get it again but perhaps with less severe symptoms. Since this is our first experience with this virus, we can only speculate about this.
I suggest you have a telephone or tele-health visit with your doctor until the pandemic has subsided.
Telehealth is a wonderful addition to the practice of medicine, especially now when having a patient come into the clinic is particularly challenging. Almost all our patient visits are now on video or telephone. Only people who have symptoms that require a face-to-face visit are being asked to come into the clinic, and even then, we are trying to bring them in separate entrances to avoid parts of the hospital for fear of exposure.
There is so much you can learn from a video visit: you can look at someone’s abdomen and see if it is bulging; you can have them show you their legs to see if they are swollen; you can get a sense of skin color; you can check in on their mental state if they suffer from hepatic encephalopathy. We want to make sure our patients are okay at home. We really want to keep our patients at home and avoid face-to-face visits unless absolutely necessary.
No, those organs cannot be used. Every deceased donor is tested for COVID-19 because we don’t want to transplant an organ with COVID-19 into someone who is COVID-19 negative.
Right now, nothing is business as usual. Blood and platelets are in short supply and both are essential in transplant surgery. The anesthesiologists who would be on hand for transplant surgeries are being deployed to manage ventilators in the COVID units.
During COVID-19, transplant centers are focusing their attention to those who are most in need of liver transplantation, those patients who face death if they are not transplanted. If an individual is stable now, it’s better to see this pandemic through before contemplating transplant.
Call before you go anywhere. Any post-transplant patient with a fever greater than 100.5 should call their transplant coordinator. Be prepared to answer questions about upper respiratory and gastrointestinal symptoms. Follow their instructions—you may either be asked to come in to be seen or scheduled for a telehealth visit with your provider.
If you are post-transplant and, when your doctors removed your original liver, decided you were at a low risk for liver cancer recurrence, then skipping that quarterly CT scan is perfectly fine. I would rather keep you out of the hospital than bring you in; bringing you in would involve so many more risks—even getting a CT scan can poses a risk if the scanner was recently occupied by someone with COVID-19. I think it’s in your best interest to skip this quarterly screening and you’ll be able to catch right back up when the pandemic subsides.
Your child is probably not at a significant risk. A three-year-old is probably going to be asymptomatic and many young children are on very low dose immunosuppression. In any case, take the same precautions you would for yourself. Make handwashing a game, singing different songs. Be diligent about social distancing. It’s very hard for children to practice distancing safely because they want to play with their friends. You really need to teach them how to maintain distance, which is hard, but an important precaution.
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