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Spectrum of statin hepatotoxicity: Experience of the drug-induced liver injury network
Abstract
The HMG-CoA reductase inhibitors (statins) are widely prescribed for patients with hyperlipidemia and are generally well tolerated. Mild elevations in serum aminotransferases arise in up to 3% of treated patients, but clinically apparent drug-induced liver injury is rare. The aim of this study is to report the presenting features and outcomes of 22 patients with clinically apparent liver injury due to statins. Among 1,188 cases of drug-induced liver injury enrolled between 2004 and 2012 in a prospective registry by the U.S. Drug Induced Liver Injury Network, 22 were attributed to a statin. All patients were evaluated in a standard fashion and followed for at least 6 months after onset. The median age was 60 years (range 41-80), and 15 (68%) were female. The latency to onset of liver injury ranged from 34 days to 10 years (median = 155 days). Median peak levels were alanine aminotransferase 892 U/L, alkaline phosphatase 358 U/L, and total bilirubin 6.1 mg/dL. Nine patients presented with cholestatic hepatitis and 12 patients presented with hepatocellular injury, of which six had an autoimmune phenotype. Nine patients were hospitalized, four developed evidence of hepatic failure, and one died. All commonly used statins were implicated. Four patients developed chronic liver injury, of which three had an autoimmune phenotype of liver injury. Conclusion : Drug-induced liver injury from statins is rare and characterized by variable patterns of injury, a range of latencies to onset, autoimmune features in some cases, and persistent or chronic injury in 18% of patients, most of whom have an autoimmune phenotype. (Hepatology 2014;60:679–686)
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“and was found to the be the fifth highest drug associated with DILI among all drug categories in the US FDA Adverse Event Reporting System database from 1997 to 2019.4,7”
From Atorvastatin-Induced Liver Injury With Concurrent Rhabdomyolysis After a Positive Rechallenge (2025) · cites this paper as [4]
In the citing paper
“However, cases of clinically significant liver injury are rare.”
From Atorvastatin-Induced Liver Injury With Concurrent Rhabdomyolysis After a Positive Rechallenge (2025) · cites this paper as [4]
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“The incidence of statin-induced liver injury is estimated to be up to 3% in patients with the majority of cases demonstrating only minor elevations in liver enzymes that often resolve spontaneously.4”
From Atorvastatin-Induced Liver Injury With Concurrent Rhabdomyolysis After a Positive Rechallenge (2025) · cites this paper as [4]
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“Russo et al analyzed 1,188 cases of clinically significant DILI enrolled in the US Drug-Induced Liver Injury Network between 2004 and 2012, and 22 were attributed to statins.4”
From Atorvastatin-Induced Liver Injury With Concurrent Rhabdomyolysis After a Positive Rechallenge (2025) · cites this paper as [4]
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“However, the incidence of statin-related DILI remains low at 1.9% based on the US DILI Network study.4”
From Atorvastatin-Induced Liver Injury With Concurrent Rhabdomyolysis After a Positive Rechallenge (2025) · cites this paper as [4]
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Drug-Induced Acute Liver Failure: Results of a U.S. Multicenter, Prospective Study
Reuben, A., Koch, D. G., & Lee, W. M. (2010) · Hepatology · doi:10.1002/hep.23937 · Cited by 772
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Chalasani, N. P., Hayashi, P. H., Bonkovsky, H. L., Navarro, V. J., Lee, W. M., & Fontana, R. J. (2014) · American Journal of Gastroenterology · doi:10.1038/ajg.2014.131 · Cited by 860
Self-citationDrug-induced liver injury—types and phenotypes
Hoofnagle, J. H., & Björnsson, E. S. (2019) · New England Journal of Medicine · doi:10.1056/nejmra1816149 · Cited by 652
Self-citationACG Clinical Guideline: Diagnosis and Management of Idiosyncratic Drug-Induced Liver Injury
Chalasani, N. P., Maddur, H., Russo, M. W., Wong, R. J., Reddy, K. R., & on behalf of the Practice Parameters Committee of the American College of Gastroenterology (2021) · American Journal of Gastroenterology · doi:10.14309/ajg.0000000000001259 · Cited by 430
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Definition and risk factors for chronicity following acute idiosyncratic drug-induced liver injury
Medina-Caliz, I., Robles-Diaz, M., Garcia-Muñoz, B., Stephens, C., Ortega-Alonso, A., Garcia-Cortes, M., González-Jimenez, A., Sanabria-Cabrera, J. A., Moreno, I., Fernandez, M. C., et al. (2016) · Journal of Hepatology · doi:10.1016/j.jhep.2016.05.003 · Cited by 140
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Jiang, C., Diao, F., Sang, Y.-J., Xu, N., Zhu, R.-L., Wang, X.-X., Chen, Z., Tao, W.-W., Yao, B., Sun, H.-X., et al. (2017) · PLOS Genetics · doi:10.1371/journal.pgen.1006535 · Cited by 39
Antimitochondrial rather than antinuclear antibodies correlate with severe drug-induced liver injury
Weber, S., Benesic, A., Buchholtz, M.-L., Rotter, I., & Gerbes, A. L. (2021) · Digestive Diseases · doi:10.1159/000511635 · Cited by 17
Atorvastatin-Induced Liver Injury With Concurrent Rhabdomyolysis After a Positive Rechallenge
Singh, H., Khalaf, A., Kunkle, B. F., Gholami, S., Lewis, J. H., & Rangnekar, A. S. (2025) · ACG Case Reports Journal · doi:10.14309/crj.0000000000001570 · Cited by 3
Metadata
- Authors
- Russo, M. W., Hoofnagle, J. H., Gu, J., Fontana, R. J., Barnhart, H., Kleiner, D. E., Chalasani, N., & Bonkovsky, H. L.
- Venue
- Hepatology
- Published
- 2014-08
- Volume
- 60
- Issue
- 2
- Pages
- 679-686
- ISSN
- 0270-9139
- PMC
- PMC4110177
- Cited by
- 222
- References
- 3
- Language
- en
- Licence
- doi.wiley.com/10.1002/tdm_license_1.1 (tdm, 396 d)
- Funders
- National Institutes of Health (1UO1DK065201,1UO1DK065193,1UO1DKO65184,1UO1DK065211,1UO1DK065238, and 1UO1DK06F5176)
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