I have many patients for whom statin therapy is indicated, but I am hesitant to start because of baseline liver-enzyme elevations (due to nonalcoholic steatohepatitis or prior history of alcoholism or hepatitis). What would you recommend in these cases?

We must consider the patient population in which you want to start the drug. If these patients have no prior history of CAD and/or familial hyperlipidemia, you have more leeway to pursue diet or use niacin or ezetimibe (Zetia). But once you’re dealing with secondary prevention of CAD (i.e., patients who already have had a clinical cardiac event), the value of the statins is much more significant. While it is true that ezetimibe can reduce cholesterol levels, the anti-inflammatory actions of the statins make them the drug of choice in CAD patients, even to the point of possible minor liver side effects. Monitor the liver function tests carefully, but do not be alarmed over further—but minor—enzyme elevations. The American College of Cardiology/American Heart Association/National Heart, Lung, and Blood Institute Clinical Advisory on Statins states: “No specific evidence exists showing exacerbation of liver disease by statins” (Circulation. 2002;106:1024-1028).—Peter F. Cohn, MD (118-16)