Real-world comparative outcomes of atorvastatin, rosuvastatin, and lovastatin–niacin fixed-dose combination in metabolic dysfunction-associated steatotic liver disease: hepatic, metabolic, and economic perspectives

BACKGROUND: Metabolic dysfunction-associated steatotic liver disease (MASLD) is a rising global health burden linked to dyslipidemia, metabolic syndrome, and hepatic inflammation. Statins are widely prescribed in MASLD, but comparative evidence on their efficacy, safety, and cost-effectiveness remains limited. AIM: To evaluate and compare the clinical effectiveness and cost-efficiency of atorvastatin, rosuvastatin, and lovastatin-niacin fixed-dose combination [LN-FDC; commercially distributed as Linicor in Taiwan] (lovastatin plus niacin) in improving liver enzymes and lipid profiles in MASLD patients. METHODS: This retrospective cohort study analyzed electronic medical records from a teaching hospital in southern Taiwan. Of 984 screened patients, 729 were included after 1:1 propensity score matching by age, sex, and baseline ALT. Patients received daily atorvastatin (20 mg), rosuvastatin (10 mg), or LN-FDC (20/500 mg) for six months. Primary outcomes were ALT and AST changes and treatment response (≥ 30% decline); secondary outcomes included lipid profiles, adverse events, and cost-effectiveness. RESULTS: All three regimens were associated with statistically significant reductions in liver biochemistry and lipid markers over six months. LN-FDC was associated with the most substantial reductions in ALT and AST, with 53.5% achieving ≥ 30% AST decline versus < 30% with atorvastatin or rosuvastatin (p < 0.001). For ALT, LN-FDC was associated with a higher ALT response rate by six months (39.9% responders vs. ~31% in comparators, p = 0.048). While atorvastatin and rosuvastatin were associated with greater HDL-C improvements, LN-FDC was associated with decreased triglycerides and a low incremental cost-effectiveness ratio. Adverse events were infrequent but showed variation across groups. Specifically, Higher flush reactions were observed in LN-FDC patients, while higher gastrointestinal intolerance and liver enzyme elevations were shown in the atorvastatin group, and higher hyperglycemia was associated with rosuvastatin. CONCLUSION: LN-FDC appeared to be associated with greater reductions and favorable cost patterns for improving hepatic inflammation and triglycerides in MASLD, though atorvastatin and rosuvastatin could increase HDL-C. Statin therapy thus provides dual hepatic and cardiovascular benefits in MASLD, with treatment choice guided by patient-specific metabolic and economic considerations.