Liver Abnormalities to Consider when Treating Patients with IBD

On December 9 at the Advances in Inflammatory Bowel 2021 annual meeting, A. Sidney Barritt IV, MD, discussed the different liver abnormalities in patients with inflammatory bowel disease (IBD) beyond primary sclerosing cholangitis (PSC), such as nonalcoholic fatty liver disease (NAFLD), viral hepatitis, and drug-induced liver injuries (DILI).

Dr Barritt is the director of the University of North Carolina Liver Center.

As rates of obesity, diabetes, and physical inactivity increase, so too has the incidence of new NAFLD increased. In patients with IBD, NAFLD is often thought to be caused by hypoproteinemia and severe malnutrition. Severe disease, intestinal inflammation, and endotoxins can all lead to liver inflammation. As a result, patients with IBD may be at double the risk of the general population for hepatic steatosis and increased inflammation.

NAFLD can be especially difficult in patients with IBD as it is accompanied by abnormal enzymes which complicate the use of certain drugs, like azathioprine and methotrexate. This disease can also progress to cirrhosis, and is an independent risk factor for heart disease, which could affect the safety and/or timing of surgery, and could cause issues related to portal hypertension. Additionally, there is no specific pharmacotherapy for NAFLD or nonalcoholic steatohepatitis (NASH).

Dr Barritt went on to caution clinicians not to ignore the potential of alcohol involvement, especially as the COVID-19 pandemic appears to have led to higher rates of alcohol consumption.

For hepatitis C virus (HCV), Dr Barritt remarked there is “no reason not to look, no reason to wait, no reason not to treat.” In 2012, the CDC recommended screening for HCV for all “baby boomers,” and risk-based screening for everyone else. The opiate epidemic has affected HCV rates, causing a new spike in incident HCV especially among young adults. Fortunately, for 99% of patients, HCV can be cured in 8-12 weeks.

Similarly, Dr Barritt urges screening for HBV. While there are now universal vaccinations for HBV at birth, many adult patients may not be vaccinated. For immunocompetent patients, the standard 3-dose vaccination works in approximately 80% of cases. Patients who are immunosuppressed, however, often require a 3-dose re-vaccination series. While it was previously believed that patients with IBD were a high-risk group for HBV, contemporary data suggests that prevalence in this group is similar to that of the general population.

The diagnosing of drug-induced liver injury (DILI) can be troublesome, as it is difficult to distinguish between DILI, drug-induced autoimmune hepatitis, and autoimmune hepatitis. There are also many over-the-counter drugs or natural remedies that are thought to be safe, yet can cause liver injury. In fact, Dr Barritt pointed out that herbal and dietary supplements (muscle-building, weight loss, erectile dysfunction, cholesterol-lowering products) are the fastest rising category of NIH-DILI cases. There are also drugs that are well known for the liver damage they cause, like acetaminophen, statins, or isoniazid, with the most common causes of DILI being the most commonly used drugs, antibiotics. Within IBD treatment specifically, there are several classes of drugs that could cause DILI: methotrexate, azathioprine, biologics, and corticosteroids. Dr Barritt also noted that total parenteral nutrition (TPN) can cause liver injury. Overall, the advice for DILI was, “first think drugs, then pick up the phone” and call a clinical pharmacist.

Dr Barritt also mentioned primary biliary cholangitis, autoimmune hepatitis, liver abscess, gallstones, and portal vein thrombus as other liver abnormalities to consider when treating patients with IBD.

Dr Barritt’s final piece of advice spoke to multidisciplinary care: “Don’t be afraid to consult your friendly neighborhood hepatologist!”

—Allison Casey

Barrit, AS IV. Beyond PSC in the liver. Presented: Advances in Inflammatory Bowel Disease annual meeting. December 9-11. Orlando, Florida.