Stay up To date

Statin Drugs Decrease Progression to Cirrhosis in HIV/HCV Co-infected Individuals.
Oliver NT et al.
AIDS 2016 ; 30:2469-76

Introduction. Chronic HIV/HCV co-infection carries increased risk of cirrhosis, hepatocellular carcinoma, and death. Due to anti-inflammatory properties, HMG co-A inhibitors (statins) may be useful adjunctive therapy to reduce liver disease progression.

Clinical information was extracted from the Veterans Affairs HIV and HCV Clinical Case Registries (1999 – 2010). HIV-related variables included combination anti-retroviral therapy (cART) era of diagnosis, CD4 cell count, and percent time with undetectable HIV viral load. Metabolic variables included diabetes, low-HDL, and hypertension. Statin use was measured as percent time with active prescription (time-updated throughout the follow-up period). Cox proportional hazards analysis was used to determine risk factors for cirrhosis (ICD-9 or APRI>2) overall and in groups stratified by alanine aminotransferase (ALT) level above and below 40 IU/L.

The cohort included 5985 HIV/HCV co-infected veterans. The majority was black race, and the mean age at index date was 45 years. Statin use was significantly protective of cirrhosis for patients with ALT <40 IU/L; for every 30% increase in time on statin, there was a 32% decreased risk of developing cirrhosis (HR 0.68, 95% CI 0.47 -0.98). Diabetes and low-HDL were significantly associated with cirrhosis in patients with ALT > 40 IU/L (HR 1.15, p<0.04 and HR 1.3, p <0.0001).

Statin drug use is beneficial in mitigating the risk of liver disease progression for HIV/HCV co-infected patients without advanced liver disease. Low-HDL and diabetes in coinfected patients with abnormal ALT have greater risk of cirrhosis development.

Expert's Commentary

This retrospective study using the large Veteran's Affairs clinical case registries extends reports of potential benefit of HMG co-A inhibitors (statins) in liver disease progression to HIV/HCV co-infected veterans. Lower rates of liver cirrhosis and hepatocellular cancer have been reported in HCV-infected patients on statins. Here, Oliver et al report that HIV/HCV co-infected veterans on statins have a lower risk of developing cirrhosis regardless of liver enzyme levels. The study has several other interesting findings that are worth noting; first, an impressive 38% of veterans met the study definition of cirrhosis during the follow-up period. Also, in patients with elevated liver enzymes (ALT>40 IU/L) concomitant diabetes was associated with risk of cirrhosis, while this was not true in those with normal liver enzymes. This difference may have been explained by presence of steatosis in the former group. Lastly, the authors note the low percent of HIV/HCV co-infected veterans prescribed a statin, and reported that this was especially true in veterans with cirrhosis . Using the same clinical case registry we previously reported that statin utilization is low in HIV, HIV/HCV, and HCV-infected veterans who meet criteria for a statin based on the national cholesterol guidelines {Clement et al, Clin Infect Dis 2016 ; 63 :407-413}. Similarly, we found that presence of cirrhosis was associated with statin underutilization. Thus, while these patients may have the most to gain from a statin prescription, they are the least likely to receive therapy. Oliver et al, not only confirms the potential for benefit of statins in HIV/HCV co-infected patients but also further highlights the need for better education of providers of the safety and potential benefit of statins in patients with HIV/HCV and liver disease.

Pr Susanna Naggie