After review of the literature and a conversation with Mr. F’s gastroenterologist, the patient was started on a combination of simvastatin 40 mg/ezetimibe 10 mg (Vytorin). He was placed on a diet very low in saturated fats and a regimen of physical activity.

At follow-up eight weeks later, the patient’s lipid panel and liver function tests (LFTs) were rechecked. His ALT was stable at 82, with no changes in other values. His total cholesterol was down to 191, and his LDL was lower, at 126. Because of Mr. F’s stress test results and the indications of early CVD, his LDL goal was <100. His statin was changed to rosuvastatin (Crestor) 20 mg, and he continued on ezetimibe 10 mg. Instructions to follow a healthy diet and exercise were reinforced.

Twelve weeks after starting his new regimen, Mr. F returned for follow-up. His LFTs were normal, including the ALT (34), and his lipid profile was at goal, with total cholesterol 145 and LDL 79. Mr. F had continued his antiviral treatment of peginterferon alfa and ribavirin. A copy of each lab result was sent to his gastroenterologist for review. Mr. F returns for evaluation of his LFTs every 12 weeks. This schedule will continue until guidelines are set regarding the monitoring of patients with liver disease and statin therapy.


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4. Discussion

Coronary atherosclerosis is a major cause of morbidity and mortality in Western society. Deposition of cholesterol in arterial walls is central to the pathogenesis of the disease. Based on extensive research, aggressive treatment of dyslipidemia is standard practice, especially in such high-risk groups as patients with FH.7

Approximately 4.1 million Americans (1.6%) have antibody to HCV. Hepatitis C causes an estimated 10,000-12,000 deaths annually in the United States.8 Although clinically significant liver injury from statins is extremely rare, mild increases in liver enzymes can occur in 1%-3% of patients.6 Because of concerns about possible liver damage, statins are contraindicated in patients with liver disease. In Mr. F’s case, the benefit of statin therapy outweighed the risk. Statin treatment is essential to reduce the profound morbidity and mortality associated with FH. Current studies have looked at the safety of statins in patients with established liver disease and suggested that these medications are safe (perhaps even beneficial) in patients with compensated liver disease.

There is a demand for guidance on the utilization of lipid-lowering medications in the management of patients with liver disease and excessive cardiovascular risk. Certainly, more research is needed to provide adequate and safe guidelines—not just recommendations—for the treatment of these high-risk patients.

Ms. Friedrich is a family nurse practitioner with Palma Sola Medical Associates in Bradenton, Fla., and a Doctorate of Nursing Practice student at the University of South Florida in Tampa.

References

1. Yuan G, Wang J, Hegele RA. Heterozygous familial hypercholesterolemia: an underrecognized cause of early cardiovascular disease. CMAJ. 2006;174:1124-1129.
2. Sibley C, Stone NJ. Familial hypercholesterolemia: a challenge of diagnosis and therapy. Cleve Clin J Med. 2006;73:57-64.
3. Khorashadi S, Hasson NK, Cheung RC. Incidence of statin hepatotoxicity in patients with hepatitis C. Clin Gastroenterol Hepatol. 2006;4:902-907.
4. Ikeda M, Abe K, Yamada M, et al. Different anti-HCV profiles of statins and their potential for combination therapy with interferon. Hepatology. 2006;44:117-125.
5. Segarra-Newnham M, Parra D, Martin-Cooper EM. Effectiveness and hepatotoxicity of statins in men seropositive for hepatitis C virus. Pharmacotherapy. 2007;27:845-851.
6. Lewis JH, Mortensen ME, Zweig S, et al. Efficacy and safety of high-dose pravastatin in hypercholesterolemic patients with well-compensated chronic liver disease: results of a prospective, randomized, double-blind, placebo-
controlled, multicenter trial. Hepatology. 2007;46:1453-1463.
7. Cash J, Callender ME, McDougall NI, et al. Statin safety and chronic liver disease. Int J Clin Pract. 2008;62:1831-1835.
8. National Digestive Diseases Information Clearinghouse. Chronic Hepatitis C: Current Disease Management.

All electronic documents accessed September 16, 2009.