Life example Mr. Wang is in his 40s, obese, with a taste for fatty foods and a lack of exercise. Recently, his unit organized a health check-up and the results made Mr. Wang nervous: in addition to being overweight (body mass index 26 kg/m2) and having high blood pressure (135/85 mmHg), abdominal ultrasound indicated the presence of moderate fatty liver, carotid ultrasound diagnosed intimal thickening, liver function indicated elevated alanine aminotransferase, and plasma cholesterol and triglycerides were also elevated. The next day, Mr. Wang rushed to the hospital for consultation. The doctor considered that Mr. Wang had moderate fatty liver, hyperlipidemia and cardiovascular atherosclerosis, and if left unchecked, he was likely to develop steatohepatitis and even cardiovascular accidents. The doctor suggested that in addition to a healthy diet and exercise, he should also take statin lipid-lowering drugs to control the culprit “hyperlipidemia”. Mr. Wang saw many side effects on the drug’s instructions, including the possibility of liver damage. He thought, his “liver enzymes” are already abnormal, is it safe to use the drug? Fatty liver is a common chronic disease, the cause of fatty liver, in addition to alcohol consumption, is mainly related to the deposition of large amounts of fat (mainly triglycerides) in the liver due to excess nutrition, which can lead to steatohepatitis, liver fibrosis and even cirrhosis in severe cases. Abnormal lipid metabolism in the blood, especially when cholesterol increases, is deposited on the otherwise smooth arterial intima through various mechanisms, producing a white plaque made of atherosclerosis-like accumulation of lipid substances, called atherosclerosis. The gradual increase of these plaques can cause narrowing of the arterial lumen and induce cardiovascular accidents. Studies have shown that for every 1% reduction in serum triglycerides and cholesterol, the incidence of coronary heart disease decreases by 2%. Therefore, lipid-lowering treatment is very important for the prevention and treatment of cardiovascular diseases. Currently, the most commonly used lipid-lowering drugs are statins (fluvastatin, lovastatin, pravastatin, simvastatin and atorvastatin), which have been used in clinical practice since the 1980s and have been proven to significantly reduce serum cholesterol and triglyceride levels, reduce lipids in atheromatous plaques, reduce inflammation and improve endothelial function, thus effectively preventing cardiovascular and cerebrovascular disease and mortality. It has become one of the most prescribed drugs in western developed countries. Adverse reactions: increase with dose “It is a drug with three toxins”, statin lipid-lowering drugs also have side effects like other drugs. It is clinically proven that all statin lipid-lowering drugs have similar side effects, mainly liver and kidney impairment and myopathy, followed by gastrointestinal reactions such as constipation, abdominal pain, bloating and indigestion, etc. Rashes and headaches may also occur, but death is rare. Some reports of liver failure and severe myopathy in recent years have raised concerns about the safety of statin lipid-lowering drugs. In fact, the application of statin lipid-lowering drugs is quite safe, and lipid-lowering treatment can reduce the risk of cardiovascular disease and is beneficial to the prevention and treatment of cardiovascular disease. Therefore, patients with dyslipidemia need not be overly afraid of adverse effects of statin lipid-lowering drugs and refuse to use them or stop them inappropriately. Liver enzyme abnormalities are mostly transient in nature. This appears to be a common feature of statin lipid-lowering drugs, with an incidence of 0.5% to 2.0%, characterized by asymptomatic isolated transaminase abnormalities that usually occur within 12 weeks of initiation or dose increase and are dose-dependent (i.e., as the dose of statin lipid-lowering drugs increases, the incidence of transaminase elevation increases accordingly). The majority of these abnormalities are transient, and most patients will recover spontaneously even with continued use of the drug, with only a 0.7% probability of needing to discontinue the drug. There is much evidence that people with pre-existing liver disease, such as NAFLD, chronic viral hepatitis, and cirrhosis, can still benefit from statin lipid-lowering therapy without an increased risk of adverse events when using statins. American Lipid Association: Chronic liver disease is not a contraindication to statin lipid-lowering drugs Information from the U.S. Food and Drug Administration (FDA) Adverse Event Reporting System shows that a total of 30 cases of liver failure occurred in patients taking statin lipid-lowering drugs across the United States, with an incidence (about 1 in 1 million) that is not higher than the control population. In the global adverse event database, there were 22 cases of liver failure in patients taking lovastatin, an incidence of 1 in 1.14 million. Few reports of statin-associated liver disease resulting in death have been reported to date. Myopathy adverse reactions are rare. Statin lipid-lowering agents are equally rare in myopathic adverse reactions (myalgia, myositis, and rhabdomyolysis) as well as in the development of renal impairment, except for the development of rhabdomyolysis, which may be fatal. Therefore, the elderly and patients with renal insufficiency need to use statin lipid-lowering drugs with caution. During treatment with statin lipid-lowering drugs, it is recommended to suspend statin lipid-lowering drugs if the patient develops intolerable muscle symptoms, such as myalgia or markedly elevated creatine kinase, and if increased physical activity, trauma, hypothyroidism and alcohol abuse are excluded. Prevention: 3 Points to Consider The characteristics of dyslipidemia in our population are different from those in the West, with most of them being predominantly mild to moderate elevated triglyceride levels, with or without increased blood cholesterol. Therefore, doctors will treat patients with individualized, low-dose lipid-lowering drugs according to their underlying lipid levels to avoid liver damage and myopathy. Early, adequate and possibly long-term use of statins is needed for people at high risk of atherosclerosis combined with elevated blood LDL cholesterol. Of course, patients with dyslipidemia should also pay attention to the following: 1. Patients need to undergo liver and kidney function tests before the start of treatment and to be reviewed regularly in the future. When using statin lipid-lowering drugs in patients with hypothyroidism, abnormal kidney function, severe infection and advanced age with diabetes, creatine kinase levels should be measured first. 2. During the medication period, patients who show any signs and symptoms of liver damage should promptly go to the hospital for liver function testing. If the patient’s liver enzymes are more than 3 times higher than the normal line, and accompanied by poor nausea, vomiting, pain in the liver area, jaundice, etc., the doctor will consider letting the patient stop the drug. 3. If the lipid-lowering therapy is not effective, patients should not increase the dose at will, because as the dose of statins increases, the incidence of adverse reactions or toxic side effects caused by the drugs may also increase. Therefore, the dose should be adjusted by the doctor according to the patient’s response to the drug, and the interval should be 4 weeks or more. In conclusion, the long-term use of statin lipid-lowering drugs within the safe dose range is worthwhile in terms of the benefit of preventing death from cardiovascular disease. Therefore, patients need not be overly concerned about the occurrence of side effects of statin lipid-lowering drugs and refuse to use them. Like antihypertensive and hypoglycemic drugs, statin lipid-lowering drugs only control lipid levels, but cannot completely reverse abnormal lipid metabolism once and for all, and the synthesis of lipid, especially cholesterol, is a continuous process. Therefore, the treatment of lipid-lowering drugs also needs a long-term process. Of course, the dosage of drugs can be adjusted by doctors according to the lipid condition.