Recently, an original study titled “Statin Prescription Patterns and Associated Factors Among Patients with Type 2 Diabetes Mellitus Attending Diabetic Clinic at Muhimbili National Hospital, Dar es Salaam, Tanzania”1 was published by Aneth Telesphore Bideberi et al in the reputable journal “Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy”. First of all, I would like to congratulate the authors and highlight the success of their publication.
This cross-sectional, hospital-based, outpatient study examined patterns and predictors correlated with statin prescribing in patients with type 2 diabetes (T2D). This study then stratified the patients according to the risk of cardiovascular disease. Although this study was successful in identifying age, medical insurance, and hypertension as potential factors for statin prescribing, I believe the study fails to identify aspartate aminotransferase (AST) and alanine aminotransferase (ALT), which have been significantly associated with cardiovascular disease (CVD) in patients with T2D. Additionally, this study provides an incomplete understanding of patient demographics because non-alcoholic fatty liver disease (NAFLD) is not included, which remains vital in prescribing statins.
Several studies have proven that the AST and AST/ALT ratio is a predictor of cardiovascular disease. Although AST is released from several tissues, including myocardium and liver, ALT is only dependent on the liver. Thus, an increase in the AST/ALT ratio indicates CVD.2 by a variety of potential mechanisms, including increased insulin resistance, chemical mediators of inflammation, and oxidative stress.3 Lazo et al significantly correlated elevated AST and ALT levels with cardiac biomarkers; troponin T and NT-proBNP.4 Hence, cementing the role of AST and ALT in subclinical myocardial injury. Thus, to identify trends in statin prescriptions for CVD prevention, it is relevant to include AST and ALT levels in the patient profile as these are crucial markers in patients with T2D at CVD risk.
In addition, NAFLD is increasingly associated with T2D; up to 70-80% of patients with T2D have NAFLD.5 Thus, identifying and diagnosing NAFLD in patients with T2DM is critical to formulating an effective treatment plan. As NAFLD is correlated with an increased prevalence of cardiovascular disease (coronary, cerebrovascular, and peripheral vascular disease),  its diagnosis is essential in the prescription of statins to improve the prognosis in patients with T2DM.
It is apparent from the articles mentioned above that for formulating a treatment plan and evaluating statin prescription regimens in patients with T2DM at risk for CVD, the inclusion of NAFLD and transaminase levels is of immense importance. . Further large-scale studies need to be conducted with well-formulated methodology to better understand this association.
The author declares no conflict of interest for this communication.
1. Bideberi AT, Mutagaywa R. Statin prescribing patterns and associated factors in patients with type 2 diabetes mellitus attending a diabetes clinic at Muhimbili National Hospital, Dar Es Salaam, Tanzania. Diabetes, Metab Syndr Obes targets Ther. 2022;15:633–646. doi:10.2147/DMSO.S347765
2. Glinghammar B, Rafter I, Lindstrom AK, et al. Detection of mitochondrial and catalytically active alanine aminotransferase in human tissues and plasma. Int. J Mol Med. 2009;23(5):621–631. doi:10.3892/ijmm_00000173
3. Targher G, Bertolini L, Rodella S, et al. NASH predicts plasma inflammatory biomarkers independent of visceral fat in men. Obesity. 2008;16(6):1394–1399. doi:10.1038/oby.2008.64
4. Lazo M, Rubin J, Clark JM, et al. The association of liver enzymes with biomarkers of subclinical myocardial damage and structural heart disease. J Hepatol. 2015;62(4):841–847. doi:10.1016/j.jhep.2014.11.024
5. Targher G, Bertolini L, Padovani R, et al. Prevalence of nonalcoholic fatty liver disease and its association with cardiovascular disease in type 2 diabetic patients. Diabetic treatments. 2007;30(5):1212–1218. doi:10.2337/dc06-2247