Reply: Emerging role of statin therapy in the prevention and management of cirrhosis, portal hypertension, and HCC

We would like to thank the authors for their comments regarding our recent comprehensive review of the utility of statins in cirrhosis and its complications.1 Given there are multiple potential clinical scenarios in which statins may benefit persons with cirrhosis, ranging from management of portal hypertensive bleeding to chemoprevention for HCC, we felt it was important to synthesize available data into clinically relevant sections as outlined in our review. The authors cite concern regarding our conclusion that data on the use of and the safety profile of statins in decompensated cirrhosis, specifically in Child-Pugh class C liver disease, is scarce. One of the cited articles is a prospective uncontrolled trial examining the use of simvastatin in 30 patients with decompensated cirrhosis.2 However, this study included only 2 patients with Child-Pugh class C cirrhosis, limiting conclusions in this patient population. Moreover, over 50% of enrolled patients (the majority of which were Child-Pugh class B) experienced an adverse effect while on statin therapy, with the most significant side effect representing muscle injury. The LIVERHOPE-SAFETY trial, which was included in our review, also found a significant increase in the need for treatment discontinuation, primarily due to rhabdomyolysis, in those persons with Child-Pugh B and C cirrhosis.3 This was most notable in those trial participants receiving simvastatin 40 mg daily, as compared to a lower dose (20 mg) of simvastatin. While we certainly agree that these rigorous clinical trials have bolstered our understanding on the use of statins in decompensated cirrhosis, additional studies with larger sample sizes are needed to delineate the best clinical practice regarding the use of statins in patients in the most advanced stages of liver disease and high vigilance for statin-associated muscle symptoms is warranted in this population.