Tuesday, December 7, 2010

Start a statin..worry less about the liver

Adverse effects from some statins on muscle, such as myopathy and rhabdomyolysis, are rare at standard doses, and on the liver, in increasing levels of transaminases, are unusual.Stopping statin use reverses these side-effects, usually leading to a full recovery. Asymptomatic increases in concentrations of liver transaminases are recorded with all statins, but are not clearly associated with an increased risk of liver disease.

With the epidemic of obesity / metabolic syndrome.....we are (and will) see obese patients with high LDL and a slightly abnormal liver function test due to ?NASH....who is in need for a statin. How safe would it be to prescribe a statin to these people?
The recently published post hoc analysis of GREACE study has some evidence to help us. In short...GREACE study is a randomised trial of 1600 pts with CHD treated with Statin to NCEP goals(i.e LDL < 100, Chol <200) Vs regular treatment. It showed a significant reduction in cardiovascular mortality if treated to NCEP targets..over a period of upto 4 years.

In the post hoc analysis in Lancet Nov 2010 ...they took 437 patients from the initial cohort..who had abnormal liver tests( AST /ALT < 3 times normal). Of them 227 were treated with a statin and 210 without a statin. All of the 227 patients on statin had improvements in their liver function whereas the 210 not on a statin showed further increase in LFTs. Also, the pts with abnormal LFTs and on a statin showed a significant decrease in CVS mortality compared to pts with abnormal LFTs and not on statin(a 68% relative risk reduction). Surprisingly...this patient group had a significant reduction in CV mortality compared to pts with normal LFTs and on a statin!
Of the 880 patients(in the whole study) who were on a statin ....< 1% stopped it due to elevation in transaminases(>3 times normal). One caution in interpreting the results of the GREACE study is that ..the average dose of Atorvastatin used was 24 mg. This may not be adequate for some ....but given the clear benefits......they can be started on a statin with monitoring LFTs. So dont hesitate to start a statin in someone with a moderate elevation in LFTs.

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