From the Guidelines
Moderate to high intensity statins are recommended for patients with established cardiovascular disease, diabetes, or high cardiovascular risk, with specific dosing recommendations including atorvastatin 10-20 mg daily for moderate intensity and 40-80 mg daily for high intensity, and rosuvastatin 5-10 mg daily for moderate intensity and 20-40 mg daily for high intensity, as supported by the 2020 standards of medical care in diabetes 1. The choice of statin dose depends on individual cardiovascular risk, baseline LDL levels, and tolerance.
- For moderate intensity, options include:
- Atorvastatin 10-20 mg daily
- Rosuvastatin 5-10 mg daily
- Simvastatin 20-40 mg daily
- Pravastatin 40-80 mg daily
- For high intensity, options include:
- Atorvastatin 40-80 mg daily
- Rosuvastatin 20-40 mg daily It is essential to start with a lower dose and titrate up as needed while monitoring for side effects like muscle pain, as recommended by the 2019 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1. Liver function tests should be checked before starting therapy and as clinically indicated thereafter. Patients should be advised that benefits accumulate over time, with maximum cholesterol-lowering effects typically seen within 4-6 weeks of consistent use, and that statins are the drugs of choice for LDL cholesterol lowering and cardioprotection, as demonstrated by meta-analyses of over 18,000 patients with diabetes from 14 randomized trials of statin therapy 1.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Take orally with or without food, at any time of day. ( 2.1) Assess LDL-C when clinically appropriate, as early as 4 weeks after initiating rosuvastatin tablets, and adjust dosage if necessary. ( 2. 1) Adults:Recommended dosage range is 5 mg to 40 mg once daily. ( 2.1)
The proper dose of moderate to high intensity statin (HMG-CoA reductase inhibitor) therapy, as indicated by the rosuvastatin label, is 5 mg to 40 mg once daily for adults.
- Moderate-intensity statin therapy is typically defined as a daily dose that lowers LDL-C by 30% to <50% [@1@].
- High-intensity statin therapy is typically defined as a daily dose that lowers LDL-C by ≥50% [@1@]. However, the label does not explicitly define the dose range for moderate to high intensity statin therapy.
From the Research
Proper Dose of Moderate to High Intensity Statin Therapy
The proper dose of moderate to high intensity statin therapy can vary depending on the specific statin and patient population.
- High-intensity statins, such as rosuvastatin 20-40 mg and atorvastatin 40-80 mg, are anticipated to reduce LDL-C by ≥50% 2.
- The choice and dose of statin have an impact on the percentage LDL-C reduction and achievement of ≥50% reduction in LDL-C, overall and within each of the four statin benefit groups outlined by the 2013 ACC/AHA guidelines 2.
- LDL cholesterol reduction ranged from 30.2 ± 17.0% with simvastatin 10 mg to 48.2 ± 14.7% with rosuvastatin 40 mg 3.
- High-intensity statin therapy was defined as discharge prescription of atorvastatin ≥40 mg, rosuvastatin ≥20 mg, or simvastatin 80 mg 4.
- Moderate-intensity statin with ezetimibe combination therapy, such as rosuvastatin 10 mg with ezetimibe 10 mg, can be an alternative to high-intensity statin monotherapy, such as rosuvastatin 20 mg 5, 6.
Statin Dosing Considerations
Considerations for statin dosing include:
- Patient population, such as those with atherosclerotic cardiovascular disease (ASCVD) or heterozygous familial hypercholesterolaemia (HeFH) 2, 3.
- Specific statin used, such as atorvastatin, rosuvastatin, or simvastatin 2, 3, 4.
- Combination therapy with ezetimibe, which can lower LDL cholesterol concentrations effectively while reducing adverse effects 5, 6.
- Individual patient response to statin therapy, which can vary 3.