As health care providers, we are understandably hesitant to prescribe medications when we believe the treatment could have adverse effects.
But for millions of diabetics who also suffer from liver disease, our hesitancy may result in inadvertently depriving them of the care they desperately need, according to research that my colleagues and I are presenting at Digestive Disease Week® (DDW) 2018.
Nonalcoholic fatty liver disease (NAFLD), which is strongly linked to diabetes, high cholesterol, and heart disease, has become increasingly common around the world, especially in Western nations whose diets contain high levels of fat. In the U.S., NAFLD has become the most common form of chronic liver disease, with estimates that it affects more than 30 percent of the population, or about 100 million people.
Statins have been shown to be highly effective in lowering cholesterol and are frequently prescribed for individuals with diabetes and other cardiovascular risk factors. But statins can also affect the liver, so when patients with diabetes also show evidence of abnormal liver tests, many primary care doctors and cardiologists will automatically refrain from using these medications.
This reluctance is unfortunate, though, because the most common cause of morbidity and mortality for NAFLD is actually cardiovascular disease — not liver disease. Moreover, many previous studies have shown that patients with liver disease actually tolerate statins very well.
My colleagues and I at Weill Cornell Medicine were concerned that providers are under-prescribing statins for diabetic patients suffering from NAFLD, so we looked at the National Health and Nutrition Examination Survey (NHANES), a nationally-representative survey that includes comprehensive data on diagnoses and prescribed treatments. We analyzed data from 136 million weighted participants between 2005 and 2014, including adults over 18, while excluding those with a variety of confounding factors such as viral hepatitis, excessive alcohol consumption, pregnancy and other conditions.
Nearly 75 percent of the sample had hyperlipidemia (an abnormally high concentration of cholesterol in the blood), and among them, 93.5 percent were taking statins to reduce their high cholesterol levels. But those who were diabetic and had NAFLD were only one-third as likely to receive statins as those without NAFLD.
We hope that our findings convey the important message that insufficient attention has been paid to studies that have repeatedly demonstrated that statins are very well tolerated by patients with NAFLD. Other smaller studies have strongly suggested that statins are under-prescribed for this population, and our study provides more conclusive evidence, based on its very large and nationally representative sample.
Our findings demonstrate that large numbers of diabetic patients with NAFLD, despite having the appropriate indications for statin use, are not receiving medications they need.
More research is still needed on the overall efficacy of statins and their effect on the liver.
Our results, however, point clearly to the need for a major educational effort to encourage primary care providers and cardiologists to increase prescription of these potentially life-saving drugs.
Dr. Kumar is an assistant professor of medicine and the director of clinical hepatology at Weill Cornell Medical College, New York, NY. Her clinical interests include non-alcoholic fatty liver disease, viral hepatitis, genetic/autoimmune liver disease and alcoholic liver disease. Dr. Kumar also has a background in clinical research and is involved in multiple clinical trials.
Dr. Kumar presented data from the study “Do patients with abnormal liver tests and nonalcoholic fatty liver disease get statins even when indicated?” abstract Su1511, on Sunday, June 3 at noon EDT, at the Walter E. Washington Convention Center in Washington, DC. For more information about featured studies, as well as a schedule of availability for featured researchers, please visit www.ddw.org/press.