What is the recommended dosage and management plan for patients with hypercholesterolemia (high cholesterol) taking Crestor (rosuvastatin)?

Rosuvastatin (Crestor) Management for Hypercholesterolemia

For patients with high cholesterol, rosuvastatin (Crestor) should be initiated at 5-20 mg once daily with a goal of reducing LDL-C by at least 50% from baseline and achieving target LDL-C levels based on risk category. 1, 2

Dosing Recommendations

Initial Dosing:

• Standard starting dose: 10 mg once daily for most patients 1
• Special populations requiring lower starting dose (5 mg):
  • Asian patients
  • Patients with severe renal impairment (not on hemodialysis)
  • Elderly patients
  • Patients taking certain medications with interaction potential

Dose Titration:

• Check lipid levels 4-12 weeks after initiation 3
• Adjust dose based on LDL-C response and tolerability
• Maximum FDA-approved dose: 40 mg daily 1

Target Goals Based on Risk Category

1. Very High-Risk ASCVD (history of multiple ASCVD events or 1 event with multiple high-risk conditions):

   • LDL-C goal: <70 mg/dL or ≥50% reduction from baseline 2
   • If goal not achieved with maximum tolerated rosuvastatin, consider adding ezetimibe 2

2. High-Risk ASCVD:

   • LDL-C goal: <100 mg/dL 2
   • Aim for ≥50% reduction from baseline 2

3. Primary Severe Hypercholesterolemia (LDL-C ≥190 mg/dL):

   • Start with high-intensity rosuvastatin (20-40 mg)
   • Target: ≥50% reduction and/or LDL-C <100 mg/dL 3
   • If goal not achieved, consider adding ezetimibe 2

4. Diabetes without ASCVD:

   • Ages 40-75: Start with moderate-intensity rosuvastatin (5-10 mg)
   • If additional risk factors present, use high-intensity dosing (20-40 mg) 2
   • Target: ≥50% reduction in LDL-C 2

Monitoring Plan

1. Initial follow-up: Check lipid panel and liver function 4-12 weeks after starting therapy 3
2. Ongoing monitoring:
   • Lipid panel every 6-12 months once stable 2
   • Monitor for muscle symptoms (myalgia occurs in 5-10% of patients) 3
   • Periodic liver function tests

Special Considerations

Renal Impairment:

• For severe renal impairment (CrCl <30 mL/min):
  • Start at 5 mg daily
  • Do not exceed 10 mg daily 2

Combination Therapy:

• If LDL-C remains elevated despite maximum tolerated rosuvastatin:
  1. Add ezetimibe 10 mg daily (can provide additional 15-25% LDL-C reduction) 4
  2. For very high-risk patients still not at goal, consider PCSK9 inhibitor 2

Alternative Dosing:

• Every-other-day dosing (10 mg) may be considered for cost savings or in patients with mild intolerance, though it results in slightly less LDL-C reduction (39% vs 48% with daily dosing) 5

Efficacy Expectations

• Rosuvastatin 10 mg reduces LDL-C by approximately 45-50% 6, 7
• Rosuvastatin 20-40 mg reduces LDL-C by approximately 50-65% 6
• Rosuvastatin is more effective than equivalent doses of other statins:
  • 5 mg rosuvastatin ≈ 20 mg simvastatin ≈ 40 mg pravastatin 7

Common Pitfalls to Avoid

1. Underdosing: Many patients require higher doses to achieve target LDL-C reductions
2. Inadequate monitoring: Failure to check lipid levels after 4-12 weeks to assess response
3. Premature discontinuation due to minor muscle aches without checking CK levels
4. Not considering combination therapy when statin monotherapy fails to achieve targets
5. Not accounting for drug interactions that may increase risk of adverse effects

Remember that rosuvastatin can be taken at any time of day, with or without food, making it convenient for patient adherence 1. The goal is to achieve significant LDL-C reduction to improve cardiovascular outcomes.