2392 Not so Safe for All: A Case of Statin-Induced Autoimmune Hepatitis and Primary Biliary Cholangitis Overlap

Abstract

INTRODUCTION: Hydroxymethylglutaryl coenzyme A reductase inhibitors, or statins, are widely used and typically well tolerated. They are rarely associated with severe hepatotoxicity and several randomized trials have demonstrated no significant difference in incidence of persistently elevated liver function tests (LFTs) between statins and placebo. We present an interesting case of drug induced liver injury from atorvastatin resulting in autoimmune hepatitis (AIH) and primary biliary cholangitis (PBC) overlap. CASE DESCRIPTION/METHODS: A 70 year old woman with a history of stroke with residual dysarthria presented with generalized weakness and decreased appetite for one week, found to have AST of 1347, ALT 807, ALP 230, bilirubin 10.2, INR 1.47, and ferritin 221,358. She did not take any herbals or over-the-counter medications, but was on atorvastatin. Four months before presentation, she had LFTs in the 400-500s, which was attributed to atorvastatin 80mg daily. This was stopped and her LFTs normalized. One month before admission, she was started on atorvastatin 40mg daily, which was discontinued on admission. Hepatitis A, B, and C and HIV were negative, and her right upper quadrant ultrasound was unremarkable. Her workup was significant for positive ANA, dsDNA Ab, anti-centromere Ab, anti-Smith Ab, RNP Ab, F-actin Ab, and smooth muscle Ab, as well as IgG of 5,599. She underwent liver biopsy, which demonstrated panlobular active hepatitis and portal inflammation with ductitis. TPMT was normal, so she was started on azathioprine and prednisone taper for AIH/ PBC overlap. Her labs dramatically improved and on discharge, AST was 375, ALT 641, ALP 184, bilirubin 3.2, and ferritin 2784. She has continued to do well and LFTs and ferritin normalized one month after discharge. DISCUSSION: While statins generally have infrequent significant side effects, they can cause hepatocellular injury that does not improve with dose reduction. There have been case reports of statins causing AIH, but in this patient’s unusual case, atorvastatin caused an autoimmune hepatitis/ primary biliary cholangitis overlap. It is important to recognize that in patients who develop LFT elevations more than three times ULN, it may not be safe to restart statins, even at a lower dose. In addition, statin-induced AIH can cause a hyperinflammatory response with significant elevations in multiple acute phase reactants, as well as lead to numerous auto-antibodies such as in the case described.