The Impact Of Statins On Liver Enzymes?

Chronic hepatitis B and C infections may safely use statins, as they block an enzyme needed for the liver to make cholesterol, allowing the liver to remove cholesterol from the blood. Statins are highly effective and safe for most patients, but they may cause an increase in liver enzyme levels, signaling inflammation. If the increase is mild, the drug can be continued, but if severe, a different statin may be needed.

Clinicians should not withhold statin therapy for patients with altered liver enzymes. Clinical trials have shown that statin use has been associated with elevations in serum alanine aminotransferase (ALT) levels in approximately 3 of persons who have statin use. The risk of hepatic injury caused by statins is estimated to be about 1%, similar to that of patients taking a placebo.

Statins can improve marginally elevated liver enzymes, but they can also cause serious problems if the liver is damaged. Elevated levels of liver and muscle enzymes are common side effects associated with statin use, and they have been contraindicated in patients with active liver disease and persistent elevated transaminase levels. Rarely, statins have been noted to induce more serious hepatic injury, including liver injury with autoimmune features.

What is the effect of statins?

Having too much cholesterol in the blood increases the risk of heart attacks and strokes. Statins block an enzyme the liver needs to make cholesterol. This causes the liver to remove cholesterol from the blood.

While statins are highly effective and safe for most people, they have been linked to muscle pain, digestive problems and mental fuzziness in some people. Rarely, they may cause liver damage.

If you think you’re experiencing side effects from taking statins, don’t just stop taking the pills. Talk to your health care team to see if a change in how much medicine you take or even a different type of medicine might be helpful.

What are statin side effects?. Muscle pain and damage. One of the most common complaints of people taking statins is muscle pain. You may feel this pain as a soreness, tiredness or weakness in your muscles. The pain can be a mild discomfort, or it can be serious enough to make it hard to do your daily activities.

What medications raise AST and ALT levels?

Drug-induced liver injury is designated hepatocellular if the ALT levels are increased to more than twice the upper limit of the reference range, with alkaline phosphatase levels that are within the reference range or are minimally elevated. Elevation of aspartate aminotransferase (AST) greater than ALT, especially if more than 2 times greater, suggests alcoholic hepatitis. Elevation of AST less than ALT is usually observed in persons with viral hepatitis. In viral and drug-induced hepatitis, the AST and ALT levels steadily increase and peak in the low thousands range within 7-14 days. Many medications can cause increases in AST, such as acetaminophen, NSAIDs, ACE inhibitors, nicotinic acid, INH, sulfonamides, erythromycin, and antifungal agents such as griseofulvin and fluconazole. In acetaminophen overdose, transaminase levels greater than 10, 000 IU/L are also noted.

Elevated aminotransferase and bilirubin levels suggestive of subfulminant or fulminant necrosis.

With increasing hepatocellular injury, bilirubin levels are invariably increased, suggesting a worse prognosis. Normally, the total bilirubin level is less than 1. 1 mg/dL and approximately 70% is indirect (unconjugated) bilirubin. Unconjugated hyperbilirubinemia ( 80% of the total bilirubin is indirect) suggests hemolysis or Gilbert syndrome. Conjugated hyperbilirubinemia ( 50% of the total bilirubin is direct) suggests hepatocellular dysfunction or cholestasis. When the bilirubin level is above 25-30 mg/dL, extrahepatic cholestasis is an unlikely diagnosis; because the predominantly conjugated bilirubin is water soluble, it is easily excreted by the kidney in extrahepatic cholestasis.

Can statins raise bilirubin levels?

Several studies have reported that statins occasionally cause impairment of liver functions characterized by elevated serum bilirubin levels, which might be due to altered function of the multidrug resistance-associated proteins (Mrp2/3).

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What enzyme makes cholesterol in the liver?

The rate-limiting enzyme in cholesterol biosynthesis is 3-hydroxy-3-methylglutaryl coenzyme A (HMG- CoA) reductase, a microsomal enzyme which converts HMG-COA to mevalonic acid in the polyisoprenoid synthetic pathway.

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What is the mechanism of action of statins?

Diabetes mellitus: Individuals taking high-intensity statins have a slightly increased risk of developing diabetes mellitus. The proposed mechanism is that statins inhibit the biosynthesis of cholesterol, which is essential for the production of GLUT-1, which mediates glucose uptake into the cell. This mechanism results in increased plasma concetrations of glucose.

Do statins increase alkaline phosphatase?

Many medications (eg, statins) commonly cause asymptomatic elevation of hepatic enzymes (alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase). However, clinically significant liver injury (eg, with jaundice, abdominal pain, or pruritus) or impaired liver function—ie, resulting in deficient protein synthesis (eg, with prolonged prothrombin time (PT) or with hypoalbuminemia)—is rare.

Withholding statin therapy in patients with chronic liver disease is not recommended. Statin use in patients with chronic liver disease is not different from its use in patients without baseline liver disease. In contrast, statins may have antifibrotic properties and can benefit patients with nonalcoholic steatohepatitis (NASH) and nonalcoholic fatty liver disease (NAFLD), ( 1, 2 ). The guidelines ( American Association for the Study of Liver Disease (AASLD) ) state that patients with NAFLD are at high risk for cardiovascular morbidity and mortality and that patients with NAFLD or NASH are not at higher risk for serious liver injury from statins. These guidelines confirm that statins can be used to treat dyslipidemia in patients with NAFLD, NASH, and NASH cirrhosis. Statins can be used with caution at low doses in patients with decompensated cirrhosis after overall risk:benefit analysis .

The term drug-induced liver injury (DILI) may be used to mean clinically significant liver injury or all (including asymptomatic) liver injury. DILI includes injury caused by medicinal herbs, plants, and nutritional supplements as well as medications ( 3, 4, 5 ).

How do statins work in the liver?

Statins (medically known as HMG CoA reductase inhibitors) work in the liver, inhibiting an enzyme (a substance that acts as a catalyst in organs) important in cholesterol synthesis. As a result, the liver makes less cholesterol and pulls in the cholesterol found in the bloodstream, Dr. Cambi explains.

Looking at it another way, “statins do three things,” Dr. Cambi says. “One, they lower the amount of bad cholesterol in the bloodstream that can be deposited in the arteries. Two, almost all of us have some amount of plaques, and statins stabilize the covering (what’s called the fibrous cap) over these plaques, rendering them less likely to rupture, thereby decreasing the chance of an unstable plaque or a heart attack. Three, statins put up theoretical ‘roadblocks’ in the vessel wall, helping to prevent cholesterol from being deposited in its lining.”

Statins also reduce heart attack and stroke through other non-cholesterol effects, Dr. Spatz says. “They have anti-inflammatory and antioxidant effects.”

How does cholesterol affect liver enzymes?

Cholesterol-dependent inflammatory response and cell death in the hepatocyte are influenced by the increased flux of fatty acids through mitochondrial oxidation and cholesterol-induced mitochondrial dysfunction. This leads to an increased burden of reactive oxygen intermediates, particularly in the presence of ω-6-polyunsaturated fatty acids. Cholesterol can be excreted into the bile via ABCG5/8 or after conversion into bile acids via the bile salt export pump. Excess cholesterol is converted into oxysterols, which may activate the liver X receptor, triggering the synthesis of ABCG5/8 and enzymes involved in fatty acid synthesis. Oxysterols may also activate NFκB and enhance the production of pro-IL-1β.

The hepatocyte is the only site at which significant quantities of cholesterol may be removed from the body either by excretion in form of free cholesterol or by secretion after conversion into bile acids. If the supply with cholesterol exceeds the hepatocyte’s capacity for bile acid synthesis and cholesterol secretion, the only safe mode of disposing cholesterol is the formation of cholesterol esters that are transiently stored in the hepatocyte.

Non-alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of the metabolic syndrome, with its prevalence increasing due to the increasing proportion of overweight and obese patients. NASH, a chronically progressive disease leading to fibrosis, cirrhosis, and eventually hepatocellular carcinoma, is the most common reason for terminal hepatic failure in western societies. Despite intense research, it is not clear whether NAFLD and NASH are different temporal stages of the same disease and if so, what molecular mechanisms trigger the progression. Recent evidence suggests that dietary cholesterol might play a critical role in this process.

How do statins affect liver enzymes?

Liver damage. Occasionally, statin use could cause an increase in the level of enzymes in the liver. These enzymes signal inflammation. If the increase is only mild, you can continue to take the drug. Rarely, if the increase is severe, you may need to try a different statin.

Although liver problems are rare, your health care team may order a liver enzyme test before or shortly after you begin to take a statin. You won’t need any further liver enzyme tests unless you begin to have symptoms of trouble with your liver.

Contact your health care professional immediately if you have unusual fatigue or weakness, loss of appetite, pain in your upper stomach, dark-colored urine, or yellowing of your skin or eyes.

Can high triglycerides increase liver enzymes?

High triglyceride levels can be a clue that you have fatty liver disease. Poor eating habits lead not only to high levels of fat in the bloodstream (triglycerides) but increased storage of fat throughout the body, including in the liver. Elevations in liver function tests (like ALT and AST) can indicate that fatty liver is present. Fatty liver usually does not cause symptoms, but unless reversed, fatty liver can lead to permanent liver damage and cirrhosis.

If your triglyceride levels are “very high” above 500 mg/dL you are more likely to get inflammation in your pancreas.

Inflammation of the pancreas (a condition that doctors call pancreatitis ) can cause permanent tissue damage. Symptoms can include abdominal pain, which may be severe.

What effect do statins have on fatty liver?

Use in the treatment of fatty liver. On the contrary, several studies have shown that treatment with statins can be useful in fatty liver to prevent and delay the appearance of fibrosis. In addition, statin treatment has been shown to reduce the risk of developing fatty liver. This is due to the antioxidant and anti-inflammatory properties of statins and that by decreasing cholesterol levels, the risk of fat deposits in the liver is reduced, which is very useful in liver diseases, especially in fatty liver.

In the case of patients with liver cirrhosis, the excellent safety of treatment with statins and the contribution of benefits to the control of the disease have also been demonstrated. In this sense, it has been proven that the administration of statins in cirrhosis reduces the risk of mortality by 40% compared to the absence of treatment. Moreover, infections are also reduced by 33%. Also the administration of statins to these patients decreases the risk of complications (hepatic decompensation) by 46% and helps to reduce the risk of bleeding since the pressure of the portal vein is reduced. Finally, it has been observed that the probability of developing liver cancer in patients with cirrhosis treated with statins decreases by 37%.

At our Foundation, Dr. Carreño and his team administer statin treatment to liver patients when indicated.