BOF: 20
A 46-year-old Caucasian female has been referred by her GP
for investigation of abnormal liver function tests. She has been found to have
an elevated ALT. All other biochemical indices of liver function are normal. She
is known to have type 2 diabetes mellitus (NIDDM). She takes 8 units of alcohol
per week; she is not on any drugs.
She is obese; height 1.60 metres weight 110 kgs. Her waist
circumference is 90 cms. Her BP is 140/90. No other abnormalities are detectable
clinically.
She has had an ultrasound scan which is consistent with
steatosis. She is negative for hepatitis B and C viruses; she is negative for
smooth muscle antibodies and antimitochondrial antibodies and has normal levels
of ferritin, caeruloplasmin and alpha 1 antitrypsin.
Her GP wishes to start her on a statin and asks you whether
it is safe to do so. Your reply is:
a)
The patient should have a liver biopsy first and depending on liver
histology a decision may be made.
b)
Statins should not be used until liver biochemistry returns to within
normal limits
c)
There is no evidence that this type of patient is at a higher risk of
statin induced hepatotoxicity and statins may be used
d)
Statins should not be used until the patient has reduced her body weight
to within normal limits
e)
Cardiovascular risk is not increased in these patients and hence statins
are not required
Answer:
c)
The patient has abnormal liver function tests with the main
abnormality being raised enzymes. She does not take alcohol in excess and is not
on any drugs thus these are not aetiological agents. She is obese with abdominal
obesity (waist circumference >80 cms in a Caucasian female), she has
hypertension and type 2 diabetes mellitus. Thus she has features of the
metabolic syndrome. The most likely cause of the raised enzymes is
non-alcoholic fatty liver disease (NAFLD). The ultrasound findings together with
the negative liver screen and the risk factors for NAFLD should be enough
evidence to point to this diagnosis without the need for a liver biopsy.
In patients with the metabolic syndrome (see later) the
risk of cardiovascular death is increased and if required treatment with statins
should be given, as there is no evidence that these patients are at increased
risk of statin induced hepatotoxicity.
The Metabolic Syndrome
Abdominal obesity (waist > 90 cms male > 80 cms
female-Caucasian)
Together with 2 or more of the following
§
Hypertension
§
Abnormal glucose tolerance
§
Low LDL cholesterol (low density lipoprotein cholesterol)
Last Updated :06/04/06
