What to do if liver enzymes are elevated due to atorvastatin (statin)?

From the Guidelines

If your liver enzymes are elevated due to atorvastatin, contact your healthcare provider immediately but don't stop taking the medication without medical advice. Your doctor will likely order additional liver function tests to determine the severity of the elevation. For mild elevations (less than 3 times the upper limit of normal), your doctor may recommend continuing the statin while monitoring your liver enzymes more frequently, perhaps every 4-6 weeks 1. This approach is supported by the 2021 Kasl clinical practice guidelines, which suggest that statins can be safely used in patients with nonalcoholic fatty liver disease (NAFLD) and can even decrease liver enzymes and reduce cardiovascular morbidity 1. For moderate elevations (3-5 times normal), your doctor might temporarily discontinue atorvastatin and consider switching to a different statin like pravastatin or rosuvastatin, which are less likely to affect the liver. For severe elevations (greater than 5 times normal), the medication should be stopped immediately. Your doctor may also reduce your atorvastatin dose or suggest taking it every other day instead of daily. It's essential to weigh the benefits of statins for cardiovascular protection against the risks of liver problems, as the benefits often outweigh the risks 1. In fact, statins can be used as a first-line treatment to lower LDL-C and prevent atherosclerotic cardiovascular disease in patients with NAFLD and nonalcoholic steatohepatitis (NASH) 1. Therefore, it is crucial to consult with your healthcare provider to determine the best course of action for your specific situation.

Some key points to consider:

• Statins can cause asymptomatic elevation of aminotransferases, which usually appears within 1 year of starting statins and recovers spontaneously 1.
• The administration of statins to patients with decompensated cirrhosis or acute liver failure should be avoided 1.
• Omega-3 fatty acids are not recommended as a treatment for NASH, but they may be considered for use in hypertriglyceridemia with NAFLD 1.
• Ezetimibe can be added to statin therapy if the response to the statin is insufficient 1.

Overall, the decision to continue, modify, or discontinue atorvastatin therapy should be made in consultation with your healthcare provider, taking into account your individual risk factors and medical history.

From the FDA Drug Label

1. 3 Liver Dysfunction Statins, like some other lipid-lowering therapies, have been associated with biochemical abnormalities of liver function. Persistent elevations (> 3 times the upper limit of normal [ULN] occurring on 2 or more occasions) in serum transaminases occurred in 0.7% of patients who received atorvastatin calcium in clinical trials. If serious liver injury with clinical symptoms and/or hyperbilirubinemia or jaundice occurs during treatment with atorvastatin calcium, promptly interrupt therapy. If an alternate etiology is not found, do not restart atorvastatin calcium.

What to do if liver enzymes are elevated due to atorvastatin:

• If serious liver injury with clinical symptoms and/or hyperbilirubinemia or jaundice occurs, promptly interrupt atorvastatin therapy.
• Do not restart atorvastatin if an alternate etiology is not found.
• It is recommended that liver enzyme tests be obtained prior to initiating therapy with atorvastatin and repeated as clinically indicated.
• Inform patients of the risk of liver dysfunction and instruct them to report promptly any symptoms that may indicate liver injury 2.
• Patients should be advised to report promptly any symptoms that may indicate liver injury, including fatigue, anorexia, right upper abdominal discomfort, dark urine, or jaundice 2.

From the Research

Increased Liver Enzymes due to Atorvastatin

If liver enzymes are elevated due to atorvastatin, several steps can be considered:

• Monitor liver enzymes regularly to assess the severity of the elevation 3
• Consider alternative statins, as some patients may tolerate other statins better than atorvastatin 4
• In some cases, discontinuing atorvastatin may be necessary to prevent further liver damage 5
• However, statin therapy should not be withheld in patients with preexisting liver disease, as the benefits may outweigh the risks 6

Management of Elevated Liver Enzymes

Some key points to consider in managing elevated liver enzymes due to atorvastatin include:

• Regular monitoring of liver enzymes to assess the effectiveness of treatment 3
• Considering the use of alternative treatments, such as fenofibrate, although the evidence is limited 7
• Being aware of the potential for hepatotoxicity recurrence on rechallenge with the same statin 4
• Recognizing that statin-induced liver injury may not be a class effect, and some statins may be safer than others 4

Treatment Options

Treatment options for elevated liver enzymes due to atorvastatin may include:

• Discontinuing atorvastatin and switching to an alternative statin or treatment 4, 5
• Monitoring liver enzymes closely to assess the severity of the elevation 3
• Considering the use of statins in patients with non-alcoholic fatty liver disease or non-alcoholic steatohepatitis, as they may improve serum aminotransferase levels and ultrasound findings 7