Does Crestor (rosuvastatin) need to be held in patients with Acute Kidney Injury (AKI)?

Management of Rosuvastatin in Acute Kidney Injury

Rosuvastatin (Crestor) should be temporarily discontinued in patients with acute kidney injury (AKI) until renal function has returned to baseline or stabilized.

Rationale for Holding Rosuvastatin During AKI

Rosuvastatin requires special consideration during AKI for several important reasons:

1. Increased Risk of Myopathy and Rhabdomyolysis:

   • The FDA label for rosuvastatin specifically warns that renal impairment is a risk factor for myopathy and rhabdomyolysis 1
   • The label recommends temporarily discontinuing rosuvastatin in patients experiencing an acute or serious condition at high risk of developing renal failure secondary to rhabdomyolysis 1

2. Dosing Considerations in Renal Impairment:

   • For patients with severe renal impairment (not on hemodialysis), rosuvastatin should be initiated at 5 mg once daily and should not exceed 10 mg once daily 1
   • AKI represents an acute deterioration in renal function that may require temporary medication adjustments

Clinical Decision Algorithm

1. When to Hold Rosuvastatin:

   • Immediately upon diagnosis of AKI (defined as increase in serum creatinine ≥0.3 mg/dL within 48 hours or ≥50% from baseline)
   • When patient is experiencing an acute condition that increases risk of rhabdomyolysis (e.g., sepsis, shock, severe hypovolemia, major surgery) 1

2. Monitoring During AKI:

   • Check creatine kinase (CK) levels if patient reports muscle symptoms
   • Monitor renal function daily while in acute setting
   • Assess for signs of myopathy (unexplained muscle pain, tenderness, weakness)

3. When to Restart Rosuvastatin:

   • Resume when renal function has returned to baseline or stabilized 2
   • Consider starting at a lower dose than previously used when restarting 2
   • Monitor renal function and potassium within 2-4 weeks after restarting 2

Special Considerations

• Patients on Hemodialysis: The FDA label does not specifically address rosuvastatin use during acute dialysis for AKI, but caution is warranted given the risk of myopathy with renal impairment

• Drug Interactions: Be particularly vigilant about drug interactions during AKI that might increase rosuvastatin levels and risk of toxicity, such as gemfibrozil, cyclosporine, and certain antiviral medications 1

• Cardiovascular Risk: While statins provide important cardiovascular benefits, the short-term interruption during AKI is generally considered safer than risking myopathy or rhabdomyolysis, which could worsen kidney injury

Common Pitfalls to Avoid

1. Failure to recognize AKI early: Monitor renal function regularly in at-risk patients on rosuvastatin

2. Restarting at full dose: When reinitiating therapy after AKI resolution, consider starting at a lower dose and titrating up as tolerated

3. Ignoring muscle symptoms: Any unexplained muscle pain, tenderness, or weakness in a patient with AKI who is on rosuvastatin should prompt immediate evaluation and consideration of statin discontinuation

4. Overlooking drug interactions: During AKI, metabolism of many medications changes, potentially increasing the risk of interactions with rosuvastatin

By temporarily holding rosuvastatin during AKI and restarting it appropriately after renal recovery, clinicians can minimize the risk of adverse effects while maintaining long-term cardiovascular benefits once the acute kidney injury has resolved.