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Liver Function and Statins


Introduction

Mild, asymptomatic increases in liver transaminases occur in 1–2% of patients taking statins. Asymptomatic more significant elevations >3× ULN occur in a similar percentage of patients. Severe liver injury with hepatic failure is very rare (<1/10000 for atorvastatin).

 

Baseline LFTs

  • Use caution when prescribing statins in patients with heavy alcohol use, known liver disease or in combination with fibrates
  • Baseline ALT or AST should be obtained prior to commencing therapy.
    • If baseline ALT or AST raised but < 3 × ULN:
      • NICE recommend that statin therapy should not routinely be withheld on this basis alone – consider cause
      • If statin therapy is considered to still be clinically appropriate, closer monitoring is advised e.g. repeat LFTS at 1 month, 3 months and 6 months and then annually if stable1
      • Consider A&G if unsure.
    • If baseline ALT/AST > 3 × ULN:
      • Do not initiate statin
      • Consider cause – if cause is found to be NAFLD statins may still be indicated with closer monitoring. Consider A&G if unsure.

 

Monitoring LFTs

  • NICE recommends checking LFTs at 3 months after initiation (or changing dose) and again at 12 months. They should also be checked if clinically indicated e.g. due to symptoms of hepatotoxicity.
    • If ALT or AST becomes raised but <3x ULN during treatment:
      • NICE recommends that statin therapy does not need to be routinely excluded
      • Consider if continuing therapy is safe and appropriate on an individual basis. Consider A&G if unsure
      • If statin therapy is continued closer monitoring of LFTs is advised e.g. 1 month, 3 months and 6 months and then annually if stable1.
    • If ALT or AST becomes >3 × ULN during treatment → withhold statin and repeat in 4 weeks:
      • If still >3x ULN do not restart statin and investigate 2.
      • There is no national guidance that explicitly states whether to retrial statins if LFTs normalise.
        • Multiple ICB level guidelines suggest cautiously restarting a lower dose or alternative statin and monitoring liver function tests more closely (e.g. at 1 month, 3 months, 6 months then annually) which is consistent with advice from our local lipid team
        • Consider if this approach is safe and appropriate on an individual basis and if unsure seek A&G. 3,4,5

 

References

  1. National Institute for Health and Care Excellence. (2024). Statins – Prescribing information (Lipid modification – CVD prevention). NICE Clinical Knowledge Summaries. Retrieved February 19, 2026, from https://cks.nice.org.uk/topics/lipid-modification-cvd-prevention/prescribing-information/statins/
  2. NICE (2024) Primary prevention of cardiovascular disease: Management, Lipid modification – CVD prevention. NICE Clinical Knowledge Summaries. Available at: https://cks.nice.org.uk/topics/lipid-modification-cvd-prevention/management/primary-prevention-of-cvd/(Accessed: 19 February 2026).
  3. Frimley Health and Care Integrated Care Board (2024) Lipid management tool. Frimley ICS Medicines Optimisation Board prescribing guideline. Available at: https://www.frimley.icb.nhs.uk/policies-and-documents/medicines-optimisation/prescribing-guidelines-1/cardiovascular/1239-lipid-management-tool/file(Accessed: 19 February 2026).
  4. North Central London Joint Formulary Committee and UCL Partners (2022) Lipid management: Medicines optimisation pathways. North Central London Health and Care. Available at: https://nclhealthandcare.org.uk/wp-content/uploads/2023/11/2_Lipid_Management_Pathways.pdf(Accessed: 19 February 2026)
  5. North East London Integrated Care Board (2025) Initiation of statins for primary prevention of cardiovascular disease in patients with liver disease: Position statement, Version 1.0, Review date 26 May 2028. Available at: https://primarycare.northeastlondon.icb.nhs.uk/wp-content/uploads/2025/06/Position-statement-Initiation-of-statins-for-primary-prevention-of-cardiovascular-disease-in-patients-with-Liver-disease.pdf(Accessed: 19 February 2026).

 

Page Review Information

Review date:           19 February 2026
Next review date:    19 February 2028
Clinical editors:        Dr Jack Munro Berry – RMS GP
Contributors:           Dr Rachel Cooper – Consultant Clinical Biochemist