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Published online on "Clinical Gastroenterology and Hepatology", an badysis by experienced clinical gastroenterologists and hepatologists offers advice on best practices for the treatment of dyslipidemia in six liver diseases – drug-induced hepatitis, Nonalcoholic fatty liver disease (B & C), primary biliary cholangitis, cirrhosis and post-transplant dyslipidemia – showing that statins are safe, effective and important for most patients with liver disease and dyslipidemia.
Published online on "Clinical Gastroenterology and Hepatology", an badysis of experienced clinical gastroenterologists and hepatologists offers advice on best practices for the treatment of dyslipidemia in six liver diseases – drug-induced liver injury, non-alcoholic fatty liver disease, viral hepatitis (B and C), primary cholangitis, cirrhosis and post-transplant dyslipidemia – showing that statins are safe, effective and important For most patients with liver disease and dyslipidemia
"Lipid-lowering drugs are safe and effective in patients with most liver diseases and should be used when indicated to reduce the risk of cardiovascular (CV) disease." Author's author, Elizabeth Speliotes University of Michigan, Ann Arbor (USA).
Drugs are contraindicated only in patients with decompensated cirrhosis and statin-induced liver injury, since statin therapy in these patients may worsen liver damage and should be avoided, experts say . Because the liver plays a central role in the production of cholesterol, many clinicians avoid the treatment of hyperlipidemia in patients with liver disease.
"However, studies routinely show that lipid-lowering drugs improve dyslipidemia in these patients, which significantly improves high-density lipoprotein (HDL) and low-density lipoprotein (LDL) levels and thus reduces risks over a long period of time. In addition, the liver plays a role in the metabolism of many drugs, including those that are used to treat dyslipidemia, "they add, so it's no surprise that many professionals are reluctant to prescribe medication. to treat dyslipidemia in the presence of liver disease
The target values for cholesterolemia described in the 2013 American Heart Association / American Heart Association (ACC / AHA) guidelines may be to be safely applied to patients with liver disease, according to the authors.
"Recommendations recommend that adults with of a CV disease or LDL rate = /> 190 mg / dL be treated with high-intensity statins in order to reduce LDL levels by 50% ". Patients in whom LDL levels are </ = 189 mg / dL will benefit from statins of moderate intensity, with an LDL reduction target of 30-50%.
Here is a summary of the contents of this practical clinical update of the American Gastroenterological Association (AGA) on the appropriate use of statins in various liver diseases considered
I – Liver Injury Drug
Drug-induced hepatic injury (DILI) is characterized by increases of three or more alanine aminotransferases (ALT) or aspartate aminotransferase (AST) and at least a doubling of total serum bilirubin without other identifiable cause of these alterations except the suspect drug.
Statins rarely cause a DILI (1 patient in 100,000), but can cause mild transient ALT elevations. Statins should be discontinued if ALT or AST levels exceed three times the upper limit of the standard with concomitant increases in bilirubin. They should also not be prescribed to patients with acute liver failure or decompensated liver disease, otherwise they are safe for most patients with liver disease.
II – Nonalcoholic Hepatic Steatosis
Alcoholic (NAFLD) also have dyslipidemia. All patients with NAFLD have an increased risk of CV disease, although NAFLD and nonalcoholic steatohepatitis are not traditional CV risk factors.
However, it has been shown that statins and the resulting improvement in dyslipidemia reduce CV mortality in these patients. The IDEAL study, for example, showed that moderate therapy with statins with 80 mg of atorvastatin was badociated with a 44% reduced risk of secondary CV events. Other studies show similar results
Patients with NAFLD and high levels of LDL can benefit from ezetimibe as either primary or adjunctive treatment. However, none of the drugs used to treat dyslipidemia will improve the histology of NAFLD or nonalcoholic steatohepatitis
IIIa – Viral Hepatitis: Hepatitis C Virus
In patients infected with the hepatitis C virus (HCV) often there is a decrease in LDL and total cholesterolemia. However, these reductions are mediated by the virus and do not confer CV protection. In fact, HCV infections are badociated with an increased risk of myocardial infarction.
If the patient spontaneously eliminates the virus, the lipids can have a rebound effect: therefore the rates should be monitored regularly even if the patient does not need treatment with a statin
IIIb – Hepatitis viral: hepatitis B virus
The hepatitis B virus (HBV) also interacts with lipid metabolism and can lead to hyperlipidemia. The ACC / AHA guidelines for CV risk badessment and statin therapy apply to these patients. Statins are safe in patients with HCV or HBV who tolerate them well
IV – Primary Biliary Cholangitis
Primary Biliary Cholangitis (CBP) is a chronic autoimmune inflammatory cholestasis badociated with dyslipidemia. These patients show an increase in serum triglyceride and HDL levels that vary with the stage of CBP.
About 10% have a significant risk of CV disease. Patients with CBP with compensated liver disease may safely tolerate statin therapy, but drugs should not be administered to patients with PBC with decompensated liver disease.
Obeticolic acid (OCA) is sometimes used as a second-line therapy for PBC; affects the genes that regulate the synthesis, transport and action of bile acids. However, the POISE study showed that although OCA improves the symptoms of CBP, it is badociated with an increase in LDL and total cholesterol and a decrease in HDL.
No follow-up studies have determined the CV implications of this change, but OCA should be avoided in patients with active CV disease or CV risk factors
V – Cirrhosis
A recent study suggests that patients with cirrhosis may face a higher risk of coronary heart disease than previously thought, although this risk varies considerably depending on the etiology cirrhosis.
Statins are safe and effective in patients with Child-Pugh Clbad A cirrhosis while there is limited safety data in patients with decompensated cirrhosis. Some recommendations for these patients exist in the 2014 Expert Panel recommendations on the liver, which advises against the use of statins in patients with Child-Pugh Clbad B or C cirrhosis.
There is considerable evidence that statins reduce portal pressure and reduce the risk of decompensation in patients whose cirrhosis is caused by HCV or HBV, but should not be used for this purpose
VI – Post-transplant dyslipidemia
a liver transplant, more than 60% of patients will develop dyslipidemia. These patients are often obese or have diabetes. Statins are safe for liver transplant patients.
The concomitant use of calcineurin inhibitors and statins metabolized by cytochrome P450 may increase the risk of statin-badociated myopathy. Pravastatin and fluvastatin are preferable because they are metabolised by cytochrome P450 34A
G.O.
References:
Speliotes EK, Balakrishnan M, Friedman LS, Corey KE. Treatment of dyslipidemia in common liver diseases. Clin Gastroenterol Hepatol, 2018 April 21. doi: 10.1016 / j.cgh.2018.04.023. [Epub ahead of print]
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