What is the relationship between Primary Sclerosing Cholangitis (PSC) and statins (HMG-CoA reductase inhibitors)?

From the Guidelines

Statins should be considered for patients with Primary Sclerosing Cholangitis (PSC) as they may reduce the risk of all-cause mortality and liver-related mortality, including death related to variceal bleeding, as suggested by a Scandinavian study [ 1 ].

Key Points to Consider

• The management of portal hypertension-related complications in PSC should follow AASLD and Baveno/EASL guidelines, which recommend non-selective beta blockers (NSBBs) to prevent portal hypertension-related decompensation [ 1 ].
• Statins have been shown to decrease portal hypertension in studies including patients of other aetiologies, and it is reasonable to assume that they would also have beneficial effects on CSPH-related complications in the setting of PSC [ 1 ].
• The use of statins in PSC patients may be associated with reduced risk of all-cause mortality and liver-related mortality, including death related to variceal bleeding [ 1 ].

Clinical Implications

• PSC patients with cardiovascular risk factors or those who meet standard criteria for statin therapy can be safely prescribed statins at standard doses, such as atorvastatin (10-80mg daily), rosuvastatin (5-40mg daily), or simvastatin (10-40mg daily).
• Regular monitoring of liver function tests is recommended when starting statins in PSC patients, but the medication should only be discontinued if there are significant elevations beyond the patient's baseline fluctuations.
• The theoretical benefit of statins' anti-inflammatory properties in PSC has been suggested but remains unproven in clinical studies [ 1 ].

Prioritizing Patient Outcomes

• The primary goal in managing PSC patients is to prioritize morbidity, mortality, and quality of life outcomes, and the use of statins may be a valuable adjunct in achieving these goals [ 1 ].

From the Research

PSC and Statins: Association and Benefits

• Statin use has been associated with improved outcomes in patients with primary sclerosing cholangitis (PSC) 2.
• A study found that statin use was associated with a reduced risk of all-cause mortality and death or liver transplantation in patients with PSC 2.
• The use of statins has also been linked to a lower risk of acute cholangitis in patients with PSC, with an 81% reduction in cholangitis observed in one study 3.

PSC: Disease Characteristics and Management

• PSC is a chronic, progressive, cholestatic liver disease characterized by multifocal strictures of intra and extrahepatic bile ducts 4, 5.
• The disease is often associated with inflammatory bowel disease and can lead to complications such as bacterial cholangitis, dominant strictures, and cholangiocarcinoma 5, 6.
• Current management of PSC is centered on endoscopic therapy of biliary strictures, management of complications, and close clinical monitoring for development of cholangiocarcinoma and timely referral for liver transplantation 4, 5, 6.

Statin Therapy in PSC: Potential Benefits and Mechanisms

• Statin therapy may be beneficial in preventing the development of cholangitis in patients with PSC, possibly by delaying the time to develop dominant or high-grade strictures 3.
• The exact mechanisms by which statins exert their beneficial effects in PSC are not fully understood, but may involve anti-inflammatory and immunomodulatory properties 2, 3.
• Further studies are needed to fully elucidate the potential benefits and mechanisms of statin therapy in PSC 2, 3, 6.