Statins in Non-alcoholic Steatohepatitis

Effect of Statins for Primary Prevention of Cardiovascular Disease According to the Fatty Liver Index

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) is associated with increased risk of cardiovascular disease (CVD). We investigated the primary preventive effect of statins on CVD according to the level of fatty liver index (FLI), which is a marker of NAFLD.

METHODS

We conducted a nested case-control study on the basis of a nationwide health screening cohort in Korea. The participants were divided into tertiles (T1, T2, and T3) according to their FLI score. Cases were defined as individuals who developed CVD (composite of myocardial infarction and stroke). Three controls were matched to each case and multivariable conditional logistic regression analysis was performed.

RESULTS

Within a cohort of 206,263 participants without prior CVD, 7044 individuals suffered the primary outcome. For the nested case-control study, we selected these 7044 cases along with their corresponding 20,641 matched controls. Individuals in the T3 tertiles of FLI had a higher risk of CVD than those in the T1 tertile [adjusted odds ratio (OR) 1.30; 95% confidence interval (CI) 1.20-1.40, P < 0.001]. In sub-analyses based on FLI tertiles, statin therapy was associated with a lower risk of CVD (adjusted OR 0.72; 95% CI 0.61-0.85, P < 0.001) in the T3 tertile but not in the T1 and T2 tertiles.

CONCLUSIONS

Statin therapy was associated with a reduced risk of CVD in individuals with high FLI but not in those with low FLI. Further research is needed to determine the pathophysiologic mechanism between statin and NAFLD.

Pharmacological Approaches to Nonalcoholic Fatty Liver Disease: Current and Future Therapies

Nonalcoholic fatty liver disease (NAFLD) and its more severe form, nonalcoholic steatohepatitis (NASH), can promote the development of cirrhosis, hepatocellular carcinoma, cardiovascular disease, and type 2 diabetes. Similarly, type 2 diabetes confers the greatest risk for the development of NASH, especially when associated with obesity. Although lifestyle changes are critical to success, early implementation of pharmacological treatments for obesity and type 2 diabetes are essential to treat NASH and avoid disease progression. This article reviews current guidance regarding the use of pharmacological agents such as pioglitazone, glucagon-like peptide 1 receptor agonists, and sodium-glucose cotransporter 2 inhibitors in the setting of NAFLD and NASH. It also reviews the latest information on new drugs currently being investigated for the treatment of NASH.

Statins on nonalcoholic fatty liver disease: A systematic review and meta-analysis of 14 RCTs

BACKGROUND

The prevalence of nonalcoholic fatty liver disease (NAFLD) is rising rapidly in the world. Our aim is to investigate the efficacy and safety of statins in the treatment of NAFLD.

METHODS

This study was conducted by searching The National Library of Medicine, Cochrane Library, China National Knowledge Infrastructure, Web of Science, and Wanfang Data Knowledge Service Platform databases. Literature data are expressed as mean difference (MD) and 95% confidence intervals (CIs) or relative risk and 95% CI. For I2 > 50% trials, random effect model is used for statistical analysis, otherwise fixed effect model is used.

RESULTS

Fourteen studies are selected for this meta-analysis, which includes totally 534 patients in the treatment group and 527 patients in the control group. As a result, 5 studies show that the total effective rate of the treatment group is 17% higher than that of the control group (Z = 2.11, relative risk = 1.17, 95% CI: [1.01-1.35]). Twelve studies show that alanine aminotransferase levels of the experimental group are lower than that of the control group (Z = 2.63, P = .009, MD = -5.53, 95% CI: [-9.64 to -1.41]). Eleven studies show that aspartate transaminase levels of the experimental group are lower than that of the control group (Z = 2.01, P = .04, MD = -3.43, 95% CI: [-6.77 to -0.08]). Six studies show that alkaline phosphatase levels of the experimental group are lower than that of the control group (Z = 0.79, P = .43, MD = -3.46, 95% CI: [-12.08 to 5.16]). Eight studies show that gamma-glutamyl transpeptidase levels of the experimental group are lower than that of the control group (Z = 2.04, P = .04, MD = -4.05, 95% CI: [-7.96 to -0.15]). Thirteen studies show that triglyceride levels of the experimental group are lower than that of the control group (Z = 4.15, P < .0001, MD = -0.94, 95% CI: [-1.39 to -0.50]). Eleven studies show that the total cholesterol levels of the experimental group are lower than that of the control group (Z = 5.42, P < .00001, MD = -1.51, 95% CI: [-2.05 to -0.96]). Seven studies show that low-density lipoprotein-cholesterol levels of the experimental group are lower than that of the control group (Z = 5.00, P < .00001, MD = -0.85, 95% CI: [-1.18 to -0.52]).

CONCLUSION

Statins can significantly reduce liver biochemical indicators in patients with NAFLD.

Statin can reduce the risk of hepatocellular carcinoma among patients with nonalcoholic fatty liver disease: a systematic review and meta-analysis

Currently, nonalcoholic fatty liver disease (NAFLD) is the main cause of chronic liver disease and liver-related mortality worldwide. Hepatocellular carcinoma (HCC) is a fatal complication in patients with NAFLD. However, whether statins can reduce the risk of HCC in patients with NAFLD remains controversial. We aimed to determine the relationship between statin use and HCC occurrence among patients with NAFLD. We independently retrieved related studies from PubMed, EMBASE, Cochrane Library, Web of Science, and ClinicalTrial.gov (from 1 January 2000 to 27 February 2022). The main outcome was the development of HCC. A fixed-effects model was used to merge odds ratio (OR) in the meta-analysis. Five studies involving 684 363 patients were included. The results of the meta-analysis suggested a significantly lower risk of HCC among statin users with NAFLD [OR = 0.59; 95% confidence interval (CI), 0.39-0.89; I2 = 87.90%]. Additionally, a lower risk of HCC was observed among patients with NAFLD aged less than 65 years (OR = 0.59; 95% CI, 0.46-0.77; I2 = 20.50%). Statins can reduce the risk of HCC in patients aged less than 65 years with NAFLD.

Effects of treatment of non-alcoholic fatty liver disease on heart failure with preserved ejection fraction

In the past few decades, non-alcoholic fatty liver disease (NAFLD) and heart failure with preserved ejection fraction (HFpEF) have become the most common chronic liver disease and the main form of heart failure (HF), respectively. NAFLD is closely associated with HFpEF by sharing common risk factors and/or by boosting systemic inflammation, releasing other secretory factors, and having an expansion of epicardial adipose tissue (EAT). Therefore, the treatments of NAFLD may also affect the development and prognosis of HFpEF. However, no specific drugs for NAFLD have been approved by the Food and Drug Administration (FDA) and some non-specific treatments for NAFLD are applied in the clinic. Currently, the treatments of NAFLD can be divided into non-pharmacological and pharmacological treatments. Non-pharmacological treatments mainly include dietary intervention, weight loss by exercise, caloric restriction, and bariatric surgery. Pharmacological treatments mainly include administering statins, thiazolidinediones, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter 2 inhibitors, and metformin. This review will mainly focus on analyzing how these treatments may affect the development and prognosis of HFpEF.

Gut dysbiosis in nonalcoholic fatty liver disease: pathogenesis, diagnosis, and therapeutic implications

The incidence of nonalcoholic fatty liver disease (NAFLD) is increasing recently and has become one of the most common clinical liver diseases. Since the pathogenesis of NAFLD has not been completely elucidated, few effective therapeutic drugs are available. As the "second genome" of human body, gut microbiota plays an important role in the digestion, absorption and metabolism of food and drugs. Gut microbiota can act as an important driver to advance the occurrence and development of NAFLD, and to accelerate its progression to cirrhosis and hepatocellular carcinoma. Growing evidence has demonstrated that gut microbiota and its metabolites directly affect intestinal morphology and immune response, resulting in the abnormal activation of inflammation and intestinal endotoxemia; gut dysbiosis also causes dysfunction of gut-liver axis via alteration of bile acid metabolism pathway. Because of its composition diversity and disease-specific expression characteristics, gut microbiota holds strong promise as novel biomarkers and therapeutic targets for NAFLD. Intervening intestinal microbiota, such as antibiotic/probiotic treatment and fecal transplantation, has been a novel strategy for preventing and treating NAFLD. In this article, we have reviewed the emerging functions and association of gut bacterial components in different stages of NAFLD progression and discussed its potential implications in NAFLD diagnosis and therapy.

Statins decrease overall mortality and cancer related mortality but are underutilized in NAFLD: a longitudinal analysis of 12,538 individuals

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease. NAFLD is associated with dyslipidemia, and cardiovascular mortality remains the leading cause of death. While statins are the first-line therapy in hyperlipidemia, their utilization has been suboptimal. Hence, we examined the use of statins in NAFLD and mortality.

RESEARCH DESIGN AND METHODS

Analysis was performed with the National Health and Nutrition Examination Survey (NHANES) data from 1999 to 2018. Longitudinal outcomes were assessed with survival analysis.

RESULTS

Of 12,538 NAFLD patients, 6,452 were indicated for hyperlipidemia treatment. Statin usage was highest among high-risk individuals (44.28%) and lowest among low-risk individuals (8.48%). The risk of overall (HR: 0.87, CI: 0.76 to 0.99, p = 0.04) and cancer-related (SHR: 0.73, CI: 0.54 to 0.99, p = 0.04) mortality was significantly lower in NAFLD patients with statins. There was no significant decrease in cardiovascular-related mortality.

CONCLUSION

Over concerns of hepatotoxicity and lack of evidence in reducing mortality events, statins remain underutilized in NAFLD. However, statin use was associated with a significant reduction in overall and cancer-related mortality. The lack of reduction in cardiovascular disease mortality is likely a selection bias of patients, where individuals with higher risk are more likely to receive treatment.

Management of Dyslipidemia in Patients with Non-Alcoholic Fatty Liver Disease

Purpose of Review

Patients with non-alcoholic fatty liver disease (NAFLD), often considered as the hepatic manifestation of the metabolic syndrome, represent a population at high cardiovascular risk and frequently suffer from atherogenic dyslipidemia. This article reviews the pathogenic interrelationship between NAFLD and dyslipidemia, elucidates underlying pathophysiological mechanisms and focuses on management approaches for dyslipidemic patients with NAFLD.

Recent Findings

Atherogenic dyslipidemia in patients with NAFLD results from hepatic and peripheral insulin resistance along with associated alterations of hepatic glucose and lipoprotein metabolism, gut dysbiosis, and genetic factors.

Summary

Since atherogenic dyslipidemia and NAFLD share a bi-directional relationship and are both major driving forces of atherosclerotic cardiovascular disease (ASCVD) development, early detection and adequate treatment are warranted. Thus, integrative screening and management programs are urgently needed. A stepwise approach for dyslipidemic patients with NAFLD includes (i) characterization of dyslipidemia phenotype, (ii) individual risk stratification, (iii) definition of treatment targets, (iv) lifestyle modification, and (v) pharmacotherapy if indicated.

PPAR-Targeted Therapies in the Treatment of Non-Alcoholic Fatty Liver Disease in Diabetic Patients

Peroxisome proliferator-activated receptors (PPAR), ligand-activated transcription factors of the nuclear hormone receptor superfamily, have been identified as key metabolic regulators in the liver, skeletal muscle, and adipose tissue, among others. As a leading cause of liver disease worldwide, non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) cause a significant burden worldwide and therapeutic strategies are needed. This review provides an overview of the evidence on PPAR-targeted treatment of NAFLD and NASH in individuals with type 2 diabetes mellitus. We considered current evidence from clinical trials and observational studies as well as the impact of treatment on comorbid metabolic conditions such as obesity, dyslipidemia, and cardiovascular disease. Future areas of research, such as possible sexually dimorphic effects of PPAR-targeted therapies, are briefly reviewed.