Should I initiate Statins (HMG-CoA reductase inhibitors) in patients with Diffuse Fatty Liver Disease (Steatosis)?

From the Guidelines

Starting statins in patients with diffuse fatty liver disease is recommended if they have elevated cholesterol levels or other cardiovascular risk factors, as the benefits of statin therapy in reducing cardiovascular risk and improving liver enzymes outweigh the potential risks. When considering statin therapy in patients with diffuse fatty liver disease, it is essential to individualize the decision based on the patient's overall cardiovascular risk profile, rather than the liver disease alone 1. The 2021 guidelines for the management of nonalcoholic fatty liver disease suggest that statins can be considered in patients with dyslipidemia, as they have been shown to decrease aminotransferases and poor cardiovascular outcomes in patients with NAFLD 1. Some key points to consider when starting statins in patients with diffuse fatty liver disease include:

• Common statins used include atorvastatin (10-80mg daily), rosuvastatin (5-40mg daily), and simvastatin (10-40mg daily) 1.
• Regular monitoring of liver function tests is recommended when starting therapy, typically at baseline, 12 weeks after initiation, and periodically thereafter 1.
• If patients experience muscle pain, weakness, or dark urine while taking statins, they should contact their healthcare provider immediately 1.
• The decision to start statins should ultimately be made in consultation with a healthcare provider who can assess the patient's complete cardiovascular risk profile and liver status 1. It is also important to note that statins are generally safe in patients with fatty liver disease and may actually provide benefit by improving liver enzymes and potentially reducing liver fat 1.

From the Research

Statins in Diffuse Fatty Liver Disease

• The use of statins in patients with non-alcoholic fatty liver disease (NAFLD) has been studied in several research papers 2, 3, 4, 5, 6.
• A systematic review and meta-analysis published in 2022 found that statins significantly reduced the risk of developing NAFLD, and improved liver histology and liver enzymes in patients with NAFLD 6.
• Another study published in 2022 found that statins effectively decreased liver enzymes and beneficially affected liver histology in NAFLD patients 3.
• A review published in 2018 summarized the available data on the impact of statins on NAFLD and non-alcoholic steatohepatitis (NASH), and found that statins may ameliorate NAFLD/NASH and reduce cardiovascular disease events 5.
• A systematic review and meta-analysis published in 2021 found that Mediterranean and hypocaloric dietary interventions favoring unsaturated fatty acids resulted in improvements in intrahepatic lipid content and transaminases in patients with NAFLD, but did not provide evidence on the use of statins in NAFLD 2.

Benefits of Statins in NAFLD

• Statins have been found to:

• Reduce the risk of developing NAFLD 6
• Improve liver histology, including steatosis grade and NAFLD activity score (NAS) 3, 6
• Decrease liver enzymes, including alanine transaminase (ALT), aspartate transaminase (AST), and gamma-glutamyl transferase (GGT) 3, 6
• Reduce the risk of cardiovascular disease events in patients with NAFLD/NASH 5

Considerations for Statin Use in NAFLD

• The use of statins in patients with NAFLD should be considered in the context of their overall cardiovascular risk profile and liver disease severity 5.
• The selection of a specific statin, such as atorvastatin or rosuvastatin, may be beneficial for patients with NAFLD due to their potential liver- and cardiovascular-related benefits 5.