Gastroenterologists, Hepatologists, COVID-19 and the Use of Acetaminophen
Authors: Alfonso J. Rodríguez-Morales, Jaime A. Cardona-Ospina, Maria Mónica Murillo-Muñoz
Journal: Clinical Gastroenterology and Hepatology (2020)

We read the article by Ungaro et al1Ungaro R.C. et al.Clin Gastroenterol Hepatol. 2020; ([Epub ahead of print])https://doi.org/10.1016/j.cgh.2020.03.020Abstract Full Text Full Text PDF Scopus (52) Google Scholar that discusses the potential implications of the current pandemic coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 for gastroenterologists. We agree that patients on immunosuppressive agents (immunomodulators or biologics) such as those with inflammatory bowel disease may be at a higher risk of complications during COVID-19 and require special care and preventive measures.2Rodriguez-Morales A.J. et al.Travel Med Infect Dis. 2020; ([Epub ahead of print]): 101623https://doi.org/10.1016/j.tmaid.2020.101623Crossref PubMed Scopus (1671) Google Scholar In addition, there also are concerns related to the increasing use of acetaminophen for managing the febrile illness associated with COVID-19.2Rodriguez-Morales A.J. et al.Travel Med Infect Dis. 2020; ([Epub ahead of print]): 101623https://doi.org/10.1016/j.tmaid.2020.101623Crossref PubMed Scopus (1671) Google Scholar Recent studies3Leventhal T.M. et al.Clin Gastroenterol Hepatol. 2019; 17: 2110-2116Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar have concluded that more than half of patients who present to the hospital with acetaminophen-induced acute liver injury (ALI) or acute liver failure (ALF) have undetectable levels of acetaminophen, and that clinicians should not exclude acetaminophen toxicity because of undetectable levels or withhold N-acetylcysteine for patients with ALI or ALF when acetaminophen toxicity is suspected. COVID-19 patients frequently need antipyretic/analgesic drugs. At the same time, multiple studies have reported an increase in alanine aminotransferase (up to 34.6% of patients), aspartate aminotransferase (up to 40.4% of patients), bilirubin (up to 25.1% of patients), and creatinine (up to 8.0% of patients) in those with confirmed COVID-19.2Rodriguez-Morales A.J. et al.Travel Med Infect Dis. 2020; ([Epub ahead of print]): 101623https://doi.org/10.1016/j.tmaid.2020.101623Crossref PubMed Scopus (1671) Google Scholar Hence, as Leventhal et al3Leventhal T.M. et al.Clin Gastroenterol Hepatol. 2019; 17: 2110-2116Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar noted, considering that patients with ALI usually have undetectable levels of acetaminophen, ALI/ALF should be considered in COVID-19 patients when acetaminophen ingestion is reported and very high (>2000 IU/L) aminotransferase levels are observed.4Khandelwal N. et al.Hepatology. 2011; 53: 567-576Crossref PubMed Scopus (127) Google Scholar We agree, as proposed by others,3Leventhal T.M. et al.Clin Gastroenterol Hepatol. 2019; 17: 2110-2116Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar that clinicians are advised not to dismiss the possibility of acetaminophen toxicity when faced with an undetectable serum acetaminophen level; there is still a need to use N-acetylcysteine in all patients with either a history of suspected acetaminophen poisoning or the biochemical profile that is associated with it, regardless of the presence or absence of the parent compound. This is even more important now with a potential significant increase in the use of acetaminophen owing to the COVID-19 pandemic.5Bhadelia N. Nature. 2020; 578: 193Crossref PubMed Scopus (16) Google Scholar Finally, as Ungaro et al1Ungaro R.C. et al.Clin Gastroenterol Hepatol. 2020; ([Epub ahead of print])https://doi.org/10.1016/j.cgh.2020.03.020Abstract Full Text Full Text PDF Scopus (52) Google Scholar mentioned, patients may complain of gastrointestinal symptoms such as nausea or diarrhea. We found that diarrhea was observed in 6.1% of patients (95% CI, 2.4%–9.7%) in 6 studies, including 457 patients with confirmed COVID-19.2Rodriguez-Morales A.J. et al.Travel Med Infect Dis. 2020; ([Epub ahead of print]): 101623https://doi.org/10.1016/j.tmaid.2020.101623Crossref PubMed Scopus (1671) Google Scholar What Should Gastroenterologists and Patients Know About COVID-19?Clinical Gastroenterology and HepatologyVol. 18Issue 7PreviewAmid the recent emergence of coronavirus disease 2019 (COVID-19), gastroenterologists are frequently being asked by their patients about this virus and any necessary precautions to take. COVID-19 has been of particular interest to our patients on immunosuppressive agents (immunomodulators or biologics) such as those with inflammatory bowel disease (IBD). COVID-19 has now been reported throughout the world, with more reported cases on a daily basis. We therefore aim to provide a brief overview of COVID-19 for the gastroenterology community based on currently available information to help assist with addressing our patients' questions and concerns (Table 1). Full-Text PDF