Gastroenterologists, Hepatologists, COVID-19 and the Use of Acetaminophen.

Dear Editor:

We read the article by Ungaro et al 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. In addition, there also are concerns related to the increasing use of acetaminophen for managing the febrile illness associated with COVID-19.

Recent studies 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. Hence, as Leventhal et al 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.

We agree, as proposed by others, 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.

Finally, as Ungaro et al 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.