Is Crestor (rosuvastatin) superior to Zetia (ezetimibe) for treating hypercholesterolemia in a 73-year-old patient with a solitary kidney and normal glomerular filtration rate (GFR)?

Rosuvastatin is Superior to Ezetimibe for a 73-Year-Old Patient with Solitary Kidney and Normal GFR

For a 73-year-old patient with a solitary kidney, normal GFR, and high cholesterol, rosuvastatin is the preferred treatment over ezetimibe due to its superior efficacy in reducing cardiovascular events and mortality.

Evidence-Based Recommendation

The decision between rosuvastatin (Crestor) and ezetimibe (Zetia) should be guided by:

1. Age-based cardiovascular risk assessment
2. Kidney function considerations
3. Comparative efficacy in cholesterol reduction
4. Impact on clinical outcomes

Age and Cardiovascular Risk

At 73 years of age, this patient falls into a high cardiovascular risk category regardless of other risk factors:

• Guidelines strongly recommend statin therapy for adults aged ≥50 years with CKD, even with normal GFR 1
• In elderly individuals (≥70 years), rosuvastatin has been shown to reduce the risk of cardiovascular events by 26% 1
• The 10-year risk for coronary events in patients >70 years is consistently elevated, justifying statin therapy 1

Kidney Considerations

Despite having a solitary kidney, the normal GFR is reassuring:

• KDIGO guidelines specifically recommend statin therapy for patients with CKD and eGFR ≥60 ml/min/1.73 m² (normal GFR) 1
• The prescribing information for rosuvastatin does not recommend dose adjustment until creatinine clearance is <30 mL/min/1.73 m² 1
• For patients with normal GFR, standard statin dosing is appropriate 1

Comparative Efficacy

Rosuvastatin offers superior lipid-lowering effects compared to ezetimibe:

• As monotherapy, rosuvastatin reduces LDL-C by 44.9% compared to much lower reductions with ezetimibe alone 2
• Rosuvastatin is classified as a high-intensity statin capable of lowering LDL-C by ≥50% at doses of 20-40 mg 1
• Ezetimibe is generally considered an add-on therapy when statins alone are insufficient 1

Clinical Outcomes

The most important consideration is the impact on morbidity and mortality:

• Statin therapy has demonstrated significant reductions in myocardial infarction (RR: 0.60) and stroke (RR: 0.76) in elderly patients 1
• There is no comparable mortality or cardiovascular event reduction data for ezetimibe monotherapy
• The JUPITER and HOPE-3 trials showed that rosuvastatin specifically reduced cardiovascular events in older adults 1

Treatment Algorithm

1. Initial therapy: Start with rosuvastatin 10-20 mg daily (moderate intensity)

   • Consider 5-10 mg if concerned about potential side effects in an elderly patient

2. Monitoring:

   • Check LDL-C levels 4-12 weeks after initiation
   • Monitor liver function and creatinine kinase as needed
   • Assess for muscle symptoms

3. Dose adjustment:

   • If LDL-C reduction is insufficient (<30-49%), consider increasing to 20-40 mg
   • If side effects occur, reduce dose rather than discontinuing

4. Consider adding ezetimibe:

   • Only if unable to achieve LDL-C goals with maximally tolerated rosuvastatin
   • Combination therapy can provide additional 15-16% LDL-C reduction 2, 3

Important Caveats

• Monitoring kidney function: Although the patient has normal GFR, regular monitoring is prudent with a solitary kidney
• Medication interactions: Check for potential drug interactions before initiating rosuvastatin
• Myopathy risk: Monitor for muscle symptoms, particularly at higher doses
• Diabetes risk: Statins slightly increase risk of new-onset diabetes, but cardiovascular benefits outweigh this risk

In conclusion, rosuvastatin is clearly superior to ezetimibe for this patient based on stronger evidence for cardiovascular risk reduction, which directly impacts morbidity and mortality outcomes. Ezetimibe should be reserved as an add-on therapy if LDL-C goals cannot be achieved with rosuvastatin alone.