What is the recommended statin (HMG-CoA reductase inhibitor) for a 76-year-old female patient with intolerance to rosuvastatin (Crestor)?

From the Guidelines

For a 76-year-old female patient who is intolerant to rosuvastatin, the recommended alternative statin therapy would be to initiate moderate-intensity statin therapy with pravastatin or pitavastatin, considering their better tolerability in elderly patients. According to the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1, in patients older than 75 years of age with clinical ASCVD, it is reasonable to initiate moderate- or high-intensity statin therapy after evaluation of the potential for ASCVD risk reduction, adverse effects, and drug–drug interactions, as well as patient frailty and patient preferences.

Some key points to consider when prescribing statins to elderly patients include:

• Starting with a lower dose, such as pravastatin 10-20 mg daily or pitavastatin 1-2 mg daily, to minimize the risk of side effects
• Monitoring for side effects like muscle pain, weakness, or elevated liver enzymes after 4-6 weeks
• Considering alternate-day dosing or switching to a non-statin lipid-lowering therapy like ezetimibe 10 mg daily if the initial options are not tolerated
• Reassessing cardiovascular risk versus side effect burden, as quality of life considerations become increasingly important with advanced age

The choice of statin is crucial, and pravastatin or pitavastatin are preferred due to their hydrophilic properties, which reduce muscle tissue penetration and are less dependent on cytochrome P450 metabolism, decreasing the risk of drug interactions in older adults who may be on multiple medications. As stated in the expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report 2, the choice of particular statin is a matter of preference, and clinicians are encouraged to develop familiarity and experience with one of the statins, including dosage regimen and potential drug-drug interactions.

In terms of specific dosing and monitoring, it is essential to follow the guidelines outlined in the expert panel report 2, which recommends starting with the lowest dose once daily, measuring baseline CK, ALT, and AST, and instructing the patient to report all potential adverse effects. Additionally, the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline 1 provides recommendations for statin therapy use in patients with ASCVD, including the aim of achieving a 50% or greater reduction in LDL-C levels in patients 75 years of age or younger, and a 30% to 49% reduction in LDL-C levels in patients who are intolerant to high-intensity statin therapy.

Overall, the goal of statin therapy in elderly patients is to balance the benefits of ASCVD risk reduction with the potential risks of adverse effects, while also considering patient preferences and quality of life. By following the guidelines and recommendations outlined above, clinicians can make informed decisions about statin therapy in elderly patients who are intolerant to rosuvastatin.

From the Research

Statin Alternatives for Rosuvastatin Intolerance

Given the patient's intolerance to rosuvastatin, alternative statins or combinations may be considered. The following points summarize the relevant information:

• A study from 2006 3 found that rosuvastatin was effective and well-tolerated in patients who were unable to tolerate other statins, suggesting that other statins may be suitable alternatives.
• However, a case report from 2024 4 highlights the risk of rhabdomyolysis associated with rosuvastatin, emphasizing the need for careful consideration when selecting an alternative statin.
• The combination of ezetimibe and rosuvastatin has been shown to be effective in reducing LDL-C levels 5, 6, but this may not be suitable for a patient intolerant to rosuvastatin.
• Other statins, such as atorvastatin, simvastatin, pravastatin, fluvastatin, and lovastatin, may be considered as alternatives, although the patient's specific intolerance to rosuvastatin and potential interactions with other medications should be taken into account.

Considerations for Alternative Statins

When selecting an alternative statin, the following factors should be considered:

• The patient's medical history and potential interactions with other medications
• The efficacy and safety profile of the alternative statin
• The patient's cardiovascular risk profile and LDL-C goals
• The potential for adverse effects, such as myopathy or rhabdomyolysis, associated with the alternative statin

Potential Alternative Statins

Some potential alternative statins that may be considered for a 76-year-old female patient with intolerance to rosuvastatin include:

• Atorvastatin
• Simvastatin
• Pravastatin
• Fluvastatin
• Lovastatin
• Pitavastatin
• It is essential to consult the patient's medical history and potential interactions with other medications before selecting an alternative statin.