This newly published review article, authored by a collective of experts in the field, discusses the efficacy and safety of lipid-lowering drugs (LLDs) in patients with liver disease, emphasising their cardiovascular benefits amidst potential hepatic risks. This is an issue of much clinical relevance, for example mild to moderately elevated liver enzymes are encountered frequently in patients with cardiovascular disease, often leading to discontinuation of LLDs, depriving patients of their cardiovascular protective benefits.

The authors meticulously evaluate multiple LLDs, such as statins, ezetimibe, PCSK9 inhibitors (including siRNAs against PCSK9), fibrates, bempedoic acid, icosapent ethyl and emerging drugs to lower lipoprotein (a). A central theme is the balance of benefits against the risk of drug-induced hepatotoxicity. For instance, statins, although associated with transient elevations in liver enzymes, rarely result in severe hepatotoxicity and remain integral in reducing cardiovascular disease (CVD) risks. Nevertheless, persistent elevation of alanine transferase more than 3 times the upper limit of normal means dose adjustment or withdrawal, which might be temporary, should be considered. Ezetimibe and PCSK9 inhibitors appear to offer minimal hepatic side effects but warrant monitoring in cases of pre-existing liver disease.

The article also highlights a knowledge gap regarding LLD use in patients with severe or active liver disease, as these populations are often excluded from clinical trials. The authors also discuss emerging therapies, such as bempedoic acid, and how these exhibit promise due to their anti-inflammatory and anti-fibrotic properties, potentially extending benefits beyond lipid control.

The authors advocate for individualised treatment approaches, emphasising monitoring and adjusting dosages for safety, particularly in complex cases with comorbidities. They underline the need for more robust, real-world studies to better understand the interplay between LLDs and liver health, especially for newer agents.

This paper is highly recommended, therefore, in view of its comprehensive analysis of current LLDs, and how we can balancing their cardiovascular advantages with potential hepatic risks. It underscores the necessity for further research to refine treatment strategies and optimise outcomes for patients with coexisting liver and cardiovascular conditions.