Written by David Bernstein, MD, FACP, FACG Friday, 24 July 2009 00:00
Many people have been concerned about cholesterol levels in liver disease, especially in patients with primary biliary cirrhosis. People with primary biliary cirrhosis or simply, PBC, have elevated cholesterol levels in the blood. In the early stages of the disease, the good cholesterol or HDL is markedly elevated. As the disease progresses, the paradigm switches and LDL or the bad cholesterol becomes more dominant. The ramifications of an elevated serum cholesterol in PBC are not clear. In the absence of other risk factors, most studies show that elevated cholesterol in this condition is not associated with an increased risk of heart disease. This should be good news for the many people in our area with PBC.
Many people, however, with primary biliary cirrhosis will have an elevated cholesterol and other risk factors for heart disease such as a family history of heart disease, diabetes, smoking or obesity. In these people, elevated serum cholesterol levels in PBC should be treated. That brings up the next logical question which is: How should these people be treated and what medications can be used for treating high cholesterol in PBC? The first intervention is to reduce risk factors. This can be done by the cessation of smoking, weight loss, regular exercise and eating a heart healthy diet. After these steps are taken, and if they are not successful, drug therapy is indicated. Interestingly, the medications used to treat PBC, ursodeoxycholic acid and cholestyramine, both have cholesterol-lowering properties. Despite these properties, they are not sufficient to treat high cholesterol in this group. The treatment of choice for high cholesterol in the United States is the statin family of drugs. These drugs are very effective in lowering cholesterol and are commonly prescribed. The statin family of cholesterol lowering agents has been associated with the development of abnormal biochemical liver tests and therefore there is concern regarding their use in people with liver disease. The development of serious liver injury with statin drugs is quite unusual. Statin drugs can be safely used in PBC patients or any liver patients, for that matter, if patients are closely followed. Liver patients who are started on statin drugs should have their liver enzymes monitored regularly during the course of therapy. Minimal increases in liver enzymes are acceptable and usually resolve but any significant change in liver tests should warrant cessation of statin therapy. As there are many different statin drugs in the marketplace, we are often asked to recommend one or another secondary to the varying degrees of liver injury associated with each specific drug. To the best of my knowledge, I am not aware of major differences in liver injury profiles between the various drugs. Therefore, I treat all the medications as though they are similar and recommend routine monitoring of all liver patients taking statin drugs.
(Disclaimer: The views and opinions represented are those of the author and meant for informative purposes only. For your specific questions, consult your physician.)