Clinical implications of COVID-19 in patients with metabolic-associated fatty liver disease

Table 1 risk factors associated with severe coronavirus disease 2019 in metabolic-associated fatty liver disease patients

Common risk factors for severe COVID-19 infections
Obesity	High serum IL-6 at admission
Advanced age > 65 yr	Male gender
Black race	High ferritin level at admission
Liver fibrosis	High EWS at admission
Dyslipidemia	Type 2 diabetes mellitus

EWS: Early warning score; IL-6: Interleukin-6; COVID-19: Coronavirus disease 2019.

Table 2 Analysis of liver test results in coronavirus disease 2019 patients

Test	Comments
Prolonged INR or thrombocytopenia	In one-third of sick patients
	Spontaneous coagulopathy/DIC may be present
	Thromboembolic incidents are probably frequent
	There may be a chance of ACLF
Imaging	Where chest-CT is frequently performed: Assessing liver/biliary tract disease might be helpful
	Do US, if necessary, but refrain from using US for superfluous imaging (not formally investigated)
Hypoalbuminemia	Common in people with systemic inflammatory response
	May also be a sign of acute hepatic decompensation or acute liver failure in people with pre-existing liver cirrhosis
High transaminases or bilirubin (> 3 × ULN)	Although not typical for COVID-19, ACLF may be present in patients with cirrhosis who already have liver disease
Dyselectrolytemia	Diarrhea and other GI problems might result in numerous electrolyte abnormalities
Anemia	Consider bleeding due to variceal hemorrhage in the context of MAFLD cirrhosis, portal hypertensive gastropathy or stress mucosal GI ulcer

ACLF: Acute on chronic liver failure; CT: Computed tomography; DIC: Disseminated intravascular coagulation; GI: Gastrointestinal; ULN: Upper limit of normal; US: Ultrasonography; COVID-19: Coronavirus disease 2019; MAFLD: Metabolic-associated fatty liver disease.

Table 3 Drugs and vaccines used in the management and prevention of coronavirus disease 19

Classification		Drugs
Antiviral agents		Favipiravir, molnupiravir, paxlovid, remdesivir
Immunomodulatory agents
	JAK inhibitors	Baricitinib, ruxolitinib, tofacitinib
	Monoclonal antibodies to IL-6	Sarilumab, tocilizumab
	Corticosteroids	Cortisol, dexamethasone, methylprednisolone
	Monoclonal antibodies to SARS-CoV-2	Bamlanivimab, casirivimab, etesevimab, imdevimab, sotrovimab
COVID-19 vaccines
	mRNA	BNT162b2 [Pfizer-BioNTech], mRNA-1273 [Moderna]
	Adenovirus vector	ChAdOx1-S [AstraZeneca, Oxford]; Ad26.COV2.S [Johnson and Johnson, Janssen], Sputnik-V-Gam - COVID Vac Ad5+Ad26 [Gamleaya]
	Recombinant nanoparticles	NVX-CoV2373 [Novavax]
Miscellaneous agents		Azithromycin, chloroquine, dexamethasone, fluvoxamine, hydroxychloroquine, ivermectin

COVID-19: Coronavirus disease 19; IL-6: Interleukin-6; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2.

Table 4 Hepatoxicity profile of the commonly used drugs to treat coronavirus disease 2019 infection

Medication	Hepatotoxicity pattern
Dexamethasone	None reported at the dose given for COVID
Protease inhibitors (e.g., lopinavir, ritonavir)	Mostly hepatitis pattern with ALT raise up to 6 times the normal, but rarely cholestatic pattern reported[43]
Nucleoside analogue: Remdesivir	Hepatitis pattern with mild to moderate ALT raise (up to 6 times the normal)[77]
Monoclonal antibodies to IL-6: Tocilizumab	Rarely can cause acute severe hepatitis in patients on concomitant or previous hepatotoxic drug usage[83]

ALT: Alanine transaminase; COVID: Coronavirus disease; IL-6: Interleukin-6.