Hepatitis C virus (HCV) infection is an important health issue because it affects
about 3% of the world population.It is estimated that 65–80% of HCV infections progress
to chronic disease, and more than 20–50% of patients with chronic hepatitis develop
hepatic cirrhosis. Hepatocellular carcinoma complicates 5% of the chronic hepatitis
C cases [1][2]. Combination therapy with peginterferon-ribavirin, which is currently
the standard treatment for chronic hepatitis C, shows a sustained virological response
in 55% of patients. The remaining 45% of patients do not respond to antiviral therapy
and are at risk of the HCV infection progressing to hepatic cirrhosis and hepatocellular
carcinoma [3]. In addition, because of the numerous adverse effects and possible contraindications
to the use of combination therapy with peginterferon and ribavirin, the administration
of this antiviral therapy is limited to only some patients with chronic hepatitis
C [4]. Because of these limitations, it is necessary to discover new therapeutic agents
for eradicating HCV infection. Several recent studies have shown that statins, commonly
used as cholesterol-lowering medication, can inhibit the replication of HCV [3][5][6].
Ikeda et al. [2] have reported in their 2006 study that statins can inhibit in vitro
HCV replication. Using OR6 cells infected with HCV, the authors evaluated the antiviral
activity of 5 statins: atorvastatin, fluvastatin, lovastatin, pravastatin, and simvastatin.
All statins, except pravastatin, that were tested as monotherapy inhibited viral replication.
Fluvastatin exhibited the strongest antiviral effect, whereas atorvastatin and simvastatin
showed moderate inhibitory effects, and lovastatin exhibited a weak inhibitory effect
on HCV replication. All of these statins exert a cholesterol-lowering effect by inhibiting
the activity of 3-hydroxy3-methyl-glutaryl coenzyme A (HMG-CoA) reductase, an enzyme
involved in cholesterol synthesis. Pravastatin, unlike the other tested statins, has
no antiviral activity; hence, it inhibits HCV replication not by a direct action on
HMG-CoA reductase, but by a specific antiviral mechanism [3]. In order to emphasize
the presence of an existing antiviral mechanism, the authors showed that the antiviral
activity of statins is not due to hepatotoxicity; they proved so by demonstrating
that HCV replication is not inhibited by the destruction of hepatocytes [3]. Several
in vivo studies have shown that the administration of statins in patients with chronic
HCV infection is safe and has no severe adverse effects [7][8][9]. For its replication,
HCV requires a number of proteins, which are involved in cholesterol synthesis. Statins
are considered to exert their antiviral activity by blocking these proteins. Thus,by
inhibiting HMG-CoA reductase activity, statins reduce the intracellular concentration
of geranylgeranyl pyrophosphate, which lowers the level of mevalonate necessary in
cholesterol synthesis. A strong argument in favor of this theory is the fact that
adding geranylgeraniol and mevalonate in cell cultures treated with statins leads
to the restoration of viral replication.
In the same study, Ikeda et al. [2] evaluated the possibility of replacing ribavirin
with statins in the treatment of chronic hepatitis C. The efficacy of each tested
statin was evaluated in combination therapy with interferon. All the statins, except
pravastatin, showed higher inhibition of HCV replication when used in combination
with interferon than when used as monotherapy. Interferon–fluvastatin combination
therapy had the strongest antiviral effect, and the authors consider that this treatment
is superior to standard therapy with interferon and ribavirin [3]. Another recently
published study [10], which evaluated in vitro anti-HCV activity of 5 statins, confirmed
the Japanese authors’ findings. According to these authors, mevastatin and simvastatin
administered as mono-therapy have the strongest antiviral activity; lovastatin and
fluvastatin have a moderate antiviral effect, while pravastatin has no antiviral activity.
In addition, mevastatin and simvastatin enhance the antiviral activity of interferon
α and of drugs that inhibit viral replication; mevastatin also prevents or reduces
resistance to therapy with viral replication inhibitors [10]. Results of in vivo studies
are controversial. According to the Initiating Dialysis Early and Late (IDEAL) study
published in 2009, statins combined with peginterferon–ribavirin therapy significantly
increase the sustained virological response rate, which is independent of serum lipid
levels before the initiation of antiviral therapy. The findings of this retrospective
study were not conclusive because of the small sample size; only 66 of the 3070 patients
infected with HCV genotype 1 received treatment with statins [11]. Another prospective
study [12] on 31 patients with chronic hepatitis C infection has shown that fluvastatin
alone (in commonly used doses) has a moderate, variable, and short-term antiviral
effect. However, the findings of the in vivo studies were not consistent with those
of the in vitro studies. In 2007, o’Leary et al. published a prospective study on
10 patients and reported that atorvastatin (in commonly used doses) does not inhibit
viral replication [13]. In 2009, Forde et al. [4] published a retrospective study
including 6463 HCV seropositive patients; this study showed that statins do not inhibit
viral replication in vivo. According to these authors, the discrepancy between the
results of the in vivo and in vitro studies may be attributable to several factors;
one such factor is the low level of statins in the serum than in the cell cultures,
because of the pharmacokinetic properties of statins. All statins, except pravastatin,
are largely retained in the first pass through the liver. The in vitro anti-HCV action
may be because of an adaptation of the cell cultures that makes the cells sensitive
to interferon action and increases their sensitivity to statins. As an adaptive mechanism,
HCV could undergo in vivo mutations and become resistant to statins; paradoxically,
statins could exert proviral effects by promoting the expression of low-density lipoprotein
(LDL) receptors, thereby facilitating HCV penetration into noninfected hepatocytes
[4]. Further, the same study showed that triglyceride-reducing agents, such as niacin,
may have anti-HCV activity in vivo. There may be a direct relationship between triglyceride
level and virus titer, considering that triglycerides metabolism is an intermediate
step in the life cycle of HCV. The virus is released together with very low-density
lipoprotein (VLDL) particles, and therefore, drugs such as niacin inhibit viral replication
by lowering serum triglyceride levels [14][15][16].
Elucidating the role of statins in the treatment of chronic hepatitis C is important,
and can be achieved by conducting prospective studies in large groups of patients.
extensive research is required to determine the effectiveness of triglyceride-reducing
agents for inhibiting HCV replication. Until the approval of new therapeutic agents,
the peginterferon–ribavirin combination represented the therapy of choice for chronic
viral hepatitis C. Recent data have shown that the addition of protease inhibitors
such as boceprevir or telaprevir to the classic peginterferon-ribavirin combination
therapy decreases the duration of treatment, thereby reducing the cost of treatment
and the number of adverse effects [17][18]. Further, an increase of up to 30% was
observed in the sustained virological response rates in non-responders, with naïve
and genotype 1 HCV infection, and a corresponding increase of up to 40–50% was observed
in patients showing relapse [19][20]. These recent advances have shown that statins
play a role in improving treatment outcome and increasing the quality of life of HCV
patients; however, the exact mechanism underlying their role is yet to be determined.