Response to letter regarding liver enzymes and non-alcoholic fats

Mr Editor

We thank Abdul Moeed for his comments on our article in his letter entitled: – Liver enzymes and non-alcoholic fatty liver disease: important factors in the evaluation of clinical management models in patients with type 2 diabetes.1 The main objective of our study was to determine the patterns of statin prescriptions of diabetic participants according to their risk stratification categories. According to several societies, including but not limited to the American Diabetes Associations (ADA), patients with diabetes are prescribed either high-intensity or moderate-intensity statins based on their cardiovascular risk categories.2 According to the ADA, recommendations for statin prescriptions are graded in AEs according to age, traditional risk factors (smoking history, duration of diabetes mellitus, obesity and hypertension), low density lipoproteins (LDL), presence or absence of atherosclerotic vascular disease (acute coronary disease syndrome, peripheral arterial disease and cerebrovascular events) and chronic complications of diabetes (neuropathy, retinopathy and nephropathy).2.3 Our study found that of 400 participants, 395 were eligible for statin prescription according to ADA criteria. We found that only 47.3% of participants took moderate-intensity prescriptions, while 52.3% of high-risk participants took no statin prescriptions.4 Our findings are critical, especially in the studied setting where the burden of cardiovascular disease is increasing, and calls for further studies in this area. We recommended the need to raise prescribers’ awareness of compliance with established international guidelines.

In response to Moeed, who commented critically on our failure to identify aspartate aminotransferase (AST) and alanine aminotransferase (ALT), as well as non-alcoholic fatty liver disease (NAFLD) as potential aspects when prescribing statins;1 we think Moeed missed a big picture. Our study of statin prescription patterns met well-established criteria, as noted above. In contrast, liver enzymes and NAFLD are not included in any of the graduated recommendations/guidelines for prescribing statins in diabetic patients. We have read the references cited by Moeed, the second reference describes ALT isoenzymes in plasma and mitochondria, nowhere is there any mention of the use of the AST to ALT ratio to predict cardiovascular risk in diabetes. In his third reference, Moeed cites the importance of nonalcoholic steatohepatitis (NASH) and visceral fat in men in predicting cardiovascular risk biomarkers. Although this appears to be a valid reference, it bears no relation to the results of our study.

NAFLD is a well-known risk factor for cardiovascular disease,5 shares several risk factors with diabetes and as correctly stated by Moeed; the majority of diabetic patients have NAFLD. Establishing a diagnosis of NAFLD in patients with diabetes is important for improving care, but it should be kept in mind that the standard of care guidelines already established for prescribing statins in diabetes are comprehensive. and would include eligible participants, including those with undiagnosed NAFLD. In sub-Saharan Africa and similar lower-middle-income (LMIC) countries, it will be tedious to try to diagnose NAFLD to all diabetic patients with systematic challenges, including but not limited to lack of expertise and lack of diagnostic tools. More importantly, we see no additional benefit of using NAFLD to decide on the prescription of statins in diabetic participants, because the effect of statins on the liver histology of NAFLD and the treatment or prevention of progression to fibrosis remains controversial and requires more randomized controlled trials (RCTs).5


The authors report no conflict of interest for this communication.


1. Moeed A. Liver enzymes and non-alcoholic fatty liver disease: important factors in evaluating clinical management regimens in patients with type 2 diabetes [Letter]. Diabetes Metab Syndr Obes. 2022;15:777–778. doi:10.2147/DMSO.S363684.eCollection2022

2. Cefalu WT, Berg EG, Saraco M, et al. American Diabetes Association: standards of medical care for diabetes-2021. Diabetic treatments. 2021;44(Supp.1):S15–S33. doi:10.2337/dc21-S002

3. Gupta R, Lodha S, Sharma KK, et al. Evaluation of statin prescriptions in type 2 diabetes: India Heart Watch-2. BMJ Open Diabetes Res Care. 2016;4(1):e000275. doi:10.1136/bmjdrc-2016-000275

4. 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

5. Al Ghamdi TS. Statins for patients with non-alcoholic fatty liver disease. J Endocrinol Metab. 2020;10(6):162–166. doi:10.14740/jem705

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