Jonggi Choi, MD, PhD, is an associate professor at Asan Medical Center, University of Ulsan College of Medicine, and visiting scholar at Mass General Hospital.

Jonggi Choi, MD, PhD

Shifting the Clinical Conversation Around Statins in PBC, With Jonggi Choi, MD, PhD

For many years, concerns about hepatotoxicity have contributed to hesitancy around prescribing statins in patients with chronic liver disease. While recent research has largely addressed and dispelled these concerns, a lack of studies specific to cholestatic conditions like 

A new study from Jonggi Choi, MD, PhD, and colleagues points to a reduced risk of hepatic decompensation and major liver events in patients with PBC taking statins, supporting a potential protective effect in this population.

, Choi addressed longstanding cautions around statins in liver disease head-on, explaining how his team’s findings may help shift the clinical conversation.

Check out part 1 of our discussion with Choi 

“Historically, there has been some concern and hesitancy among physicians prescribing statins in patients with chronic liver disease,” Choi acknowledged, noting that even though multiple studies have demonstrated the general safety of statins in chronic liver disease, apprehension still influences day-to-day prescribing decisions.

His study, which focused largely on stable patients with PBC, most of whom were already receiving ursodeoxycholic acid (UDCA) and had preserved liver function, found no evidence of harm associated with statin use. On the contrary, statins were linked to a significantly lower risk of future liver decompensation.

However, Choi emphasized that the findings should not be interpreted as definitive proof supporting the use of statins specifically for liver protection. Despite the use of a rigorous target trial emulation design to strengthen causal inference, he notes that the data remain observational. Still, he says the study should provide clinicians with reassurance that statins do not need to be withheld in patients with stable PBC or other chronic liver diseases when there is a clear cardiovascular indication.

Looking ahead, Choi outlined several critical next steps. Strengthening causal inference remains a priority, with confirmation ideally coming from randomized controlled trials.

He also highlighted the need for better phenotyping to determine whether statin benefits vary by fibrosis stage, biochemical response to UDCA, or coexisting metabolic risk factors. According to Choi, mechanistic studies are equally important, particularly to clarify how statins’ anti-inflammatory and antifibrotic effects interact with autoimmune cholestatic injury in PBC.

“I see this study as a strong signal-generating step that opens the door for both clinical trials and more refined observational narratives,” Choi said.

Editors’ Note: Choi reports relevant disclosures with Gilead.

Choi J, Xu J, Nguyen VH, et al. Association between statin use and hepatic decompensation in patients with primary biliary cholangitis: A target trial emulation study. 

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Choi explains longstanding hesitancy around statin use in chronic liver disease, particularly cholestatic diseases like PBC, and how his research challenges these sentiments.

Statins and Improved Long-Term Liver Outcomes in PBC, With Jonggi Choi, MD, PhD

Statins are widely recognized as cholesterol-lowering agents, but over the past decade, accumulating evidence has suggested their benefits may extend beyond lipid management.

 highlights a reduced risk of hepatic decompensation and major liver events in patients with primary biliary cholangitis (PBC) taking statins, supporting a potential protective effect in this population.

“Several large observational studies have suggested that statins may slow liver fibrosis, reduce complications related to portal hypertension, and even lower the risk of liver cancer,” Jonggi Choi, MD, PhD, an associate professor at Asan Medical Center, University of Ulsan College of Medicine, and visiting scholar at Mass General Hospital, told HCPLive. “About a year ago, our group also published a large case study in 

 showing that statin use was associated with improved outcomes in patients with overall chronic liver disease, which further raised interest in their potential liver protective effects. However, when it comes to PBC, the evidence has been much more limited.”

He noted that PBC is a rare autoimmune cholestatic liver disease characterized by chronic inflammation and progressive destruction of the small bile ducts, ultimately leading to cirrhosis if left untreated. Most prior studies in PBC, he explained, focused on short-term laboratory changes rather than clinically meaningful long-term outcomes like liver failure, transplantation, or cancer. As a result, whether statins influence the long-term course of PBC has remained unclear.

Because randomized controlled trials are particularly challenging in rare diseases like PBC, investigators used a target trial emulation approach with real-world data. As Choi described, this method structures observational data to closely mimic a randomized clinical trial, helping to minimize common biases such as immortal time bias.

Using 2 large, independent electronic health record databases from Mass General Brigham and Asan Medical Center, investigators identified statin initiation on a month-by-month basis. In each monthly trial, statin initiators were matched in a 1:2 ratio to non-users using propensity score matching.

The primary outcome was hepatic decompensation while the secondary outcome was a composite major adverse liver outcome (MALO), including decompensation, hepatocellular carcinoma, and liver transplantation.

Among 2889 eligible patients, 443 statin users were matched to 886 non-users. During a median follow-up of 3.8 years, hepatic decompensation occurred in 24 statin users (5.4%) and in 67 non-users (7.6%) (hazard ratio [HR], 0.61; 95% confidence interval [CI]: 0.38–0.97). Statin use was additionally associated with a reduced risk of MALO (HR, 0.58; 95% CI: 0.38–0.89).

Importantly, Choi noted sensitivity analyses stratified by data source (MGB, HR 0.65; AMC, HR 0.60) and cirrhosis status (HR 0.70 for cirrhosis; HR 0.57 for without) showed similar directional trends, indicating that results were consistent across different groups.

Choi J, Nguyen VH, Przybyszewski E, et al. Statin Use and Risk of Hepatocellular Carcinoma and Liver Fibrosis in Chronic Liver Disease. 

 2025;185(5):522–530. doi:10.1001/jamainternmed.2025.0115

Choi describes existing evidence on statin use in patients with liver disease and reviews his new research about their potential utility in PBC.

Jonggi Choi, MD, PhD

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