Yes! Statins can be given to liver patients.

Statins are given to 10–20% of adults in developed countries. Statins increase alanine aminotransferase (ALT) concentrations in 10% of patients without liver disease, and this increase can exceed more than three times the upper limit of normal in 1% of such patients. In contrast, we will note that this ALT escalation does not appear to occur when statins are initiated in patients with fatty liver or hepatitis C. In the field of drug-induced liver disease, attempts are made to distinguish between medicines that cause hepatotoxic reactions and idiosyncratic reactions. The principal differences are that hepatotoxic reactions are dose dependent and predictable (e.g., acetaminophen); while idiosyncratic reactions are not dose dependent or predictable (e.g., penicillin). Do statins cause liver injury? This author has asserted with voluminous supporting data that statins are not hepatotoxic [1]. Do statins cause rare idiosyncratic drug reactions? Probably. In this issue, Bjornsson et al. present an epidemiological survey of a monitoring system using RUCAM methodology to discover drug toxicity [2]. The strengths of their work are the authors’ experience, the 22 years of observation, and that the database is limited to a single country, Sweden. The report is fortified by their addition of drug rechallenge cases, though drug rechallenge is not the gold standard it was once thought. Positive rechallenge cases have sometimes been discovered to accidentally take the identical drug on a subsequent date without a problem; conversely, negative rechallenge cases sometimes experience a similar idiosyncratic reaction later on the same drug. The problem lies partly in cross reactivity of chemical moieties. The sensitivity and specificity of a drug rechallenge to determine the cause of an idiosyncratic reaction is poorly understood [3]. The weakness of the study is the reliance upon the Roussel Uclaf Causality Assessment Method (RUCAM). RUCAM is a scoring method that attempts to quantify clinical judgment. Amongst a multitude of problems, the RUCAM suffers from a high degree of interobserver variability [4,5]. Moreover, it is prejudicial against statins by begging the question. That is, RUCAM scoring assigns two points for a drug-induced liver reaction if the product label contains a liver injury notation. As I have noted elsewhere, the product labels of statins are terribly outdated with liver