Can a patient with Metabolic Associated Steatohepatitis Liver Disease (MASLD), deranged liver function tests, specifically elevated Serum Glutamic-Oxaloacetic Transaminase (SGOT) and Serum Glutamic-Pyruvic Transaminase (SGPT), and dyslipidemia be prescribed statins, such as atorvastatin (Lipitor) or rosuvastatin (Crestor)?

Statins in Patients with MASLD and Elevated Liver Enzymes

Yes, statins can and should be prescribed to patients with Metabolic Associated Steatotic Liver Disease (MASLD), elevated liver enzymes (SGOT/SGPT), and dyslipidemia as they are safe and effective in this population. 1

Safety of Statins in MASLD

Statins are specifically recommended for patients with chronic liver disease, including those with compensated cirrhosis, according to the European Association for the Study of the Liver (EASL) guidelines. They should be used according to cardiovascular risk guidelines to reduce cardiovascular events, which are a major cause of mortality in MASLD patients 1.

The misconception that statins are contraindicated in liver disease is not supported by current evidence:

• Statin therapy is safe in patients with MASLD and elevated transaminases 2
• Statins are often underused in MASLD patients despite being an effective therapy across the spectrum of non-alcohol related steatotic liver diseases 2
• Asymptomatic increases in transaminases (>3 times upper limit of normal) are infrequent statin-associated side effects that often resolve with dose reduction or rechallenge with alternative statins 1

Monitoring Recommendations

When starting statins in a patient with MASLD and elevated liver enzymes:

1. Baseline testing:

   • Measure liver enzymes (ALT/AST) before starting treatment 1
   • Check baseline CK if patient has risk factors (elderly, concomitant medications, renal disease) 1

2. Follow-up monitoring:

   • Check liver enzymes 8-12 weeks after starting treatment or after dose increase 1
   • Routine monitoring of ALT thereafter is not recommended during statin therapy 1

3. If liver enzymes become elevated:

   • If ALT <3× ULN: Continue therapy and recheck liver enzymes in 4-6 weeks 1
   • If ALT ≥3× ULN: Stop statin or reduce dose and recheck liver enzymes 1

Statin Selection in MASLD

When selecting a statin for patients with MASLD:

• Preferred options: Atorvastatin or rosuvastatin are considered efficacious statins that can improve the atherogenic lipid profile in metabolic syndrome 3
• Dosing consideration: Consider starting at lower doses and titrating up as tolerated 1
• Alternative dosing: If not tolerated daily, consider alternate day or once/twice weekly dosing regimens 1

Benefits Beyond Lipid Lowering

Statins provide additional benefits for MASLD patients:

• Cardiovascular risk reduction, which is particularly important as cardiovascular disease is the leading cause of death in MASLD patients 4
• Potential beneficial effects on liver histology in some patients with MASLD 5
• Improvement in the overall atherogenic dyslipidemia associated with metabolic syndrome 3

Special Considerations

• For patients with decompensated cirrhosis, statins should be avoided 5
• In patients with compensated cirrhosis (Child-Pugh A), statins can be used safely 1
• If statin-associated muscle symptoms develop, follow a systematic approach of reassess, rediscuss, and rechallenge 1

Conclusion

The benefits of statin therapy in patients with MASLD, elevated liver enzymes, and dyslipidemia outweigh the potential risks. Regular monitoring of liver function is recommended initially, but routine long-term monitoring is not necessary in the absence of symptoms. Cardiovascular risk reduction should be prioritized in this high-risk population.