Simvastatin and Rifaximin in Decompensated Cirrhosis
Authors: Pose Elisa , Jiménez César , Zaccherini Giacomo , Campion Daniela , Piano Salvatore , Uschner Frank Erhard , de Wit Koos , Roux Olivier , Gananandan Kohilan , Laleman Wim , Solé Cristina , Alonso Sonia , Cuyàs Berta , Ariza Xavier , Juanola Adrià , Ma Ann T. , Napoleone Laura , Gratacós-Ginès Jordi , Tonon Marta , Pompili Enrico , Sánchez-Delgado Jordi , Allegretti Andrew S. , Morales-Ruiz Manuel , Carol Marta , Pérez-Guasch Martina , Fabrellas Núria , Pich Judit , Martell Claudia , Joyera María , Domenech Gemma , Ríos José , Torres Ferrán , Serra-Burriel Miquel , Hernáez Rubén , Solà Elsa , Graupera Isabel , Watson Hugh , Soriano Germán , Bañares Rafael , Mookerjee Rajeshwar P. , Francoz Claire , Beuers Ulrich , Trebicka Jonel , Angeli Paolo , Alessandria Carlo , Caraceni Paolo , Vargas Víctor M. , Abraldes Juan G. , Kamath Patrick S. , Ginès Pere ,   LIVERHOPE Consortium
Published: February 2025

ImportanceThere are no useful treatments to prevent the development of severe complications of liver cirrhosis. Simvastatin and rifaximin have shown beneficial effects in liver cirrhosis.ObjectiveTo assess whether simvastatin combined with rifaximin improves outcomes in patients with decompensated cirrhosis.Design, Setting, and ParticipantsDouble-blind, placebo-controlled, phase 3 trial conducted among patients with decompensated cirrhosis in 14 European hospitals between January 2019 and December 2022. The last date of follow-up was December 2022.InterventionsPatients were randomly assigned to receive simvastatin, 20 mg/d, plus rifaximin, 1200 mg/d (n = 117), or identical-appearing placebo (n = 120) for 12 months in addition to standard therapy, stratified according to Child-Pugh class B or C.Main Outcomes and MeasuresThe primary end point was incidence of severe complications of liver cirrhosis associated with organ failure meeting criteria for acute-on-chronic liver failure. Secondary outcomes included transplant or death and a composite end point of complications of cirrhosis (ascites, hepatic encephalopathy, variceal bleeding, acute kidney injury, and infection).ResultsAmong the 237 participants randomized (Child-Pugh class B: n = 194; Child-Pugh class C: n = 43), 72% were male and the mean age was 57 years. There were no differences between the 2 groups in terms of development of acute-on-chronic liver failure (21 [17.9%] vs 17 [14.2%] patients in the treatment and placebo groups, respectively; hazard ratio, 1.23; 95% CI, 0.65-2.34; P = .52); transplant or death (22 [18.8%] vs 29 [24.2%] patients in the treatment and placebo groups, respectively; hazard ratio, 0.75; 95% CI, 0.43-1.32; P = .32); or development of complications of cirrhosis (50 [42.7%] vs 55 [45.8%] patients in the treatment and placebo groups, respectively; hazard ratio, 0.93; 95% CI, 0.63-1.36; P = .70). Incidence of adverse events was similar in both groups (426 vs 419; P = .59), but 3 patients in the treatment group (2.6%) developed rhabdomyolysis.Conclusions and RelevanceThe addition of simvastatin plus rifaximin to standard therapy does not improve outcomes in patients with decompensated liver cirrhosis.Trial RegistrationClinicalTrials.gov Identifier: NCT03780673