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 primary biliary cholangitis (PBC) have resulted in continued hesitancy.

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.

In an interview with HCPLive, 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 here.

“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.

References

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. Hepatology. doi:10.1097/HEP.0000000000001701