Recommended Crestor Dosing for 18% ASCVD Risk
For a patient with an 18% 10-year ASCVD risk, initiate rosuvastatin 20 mg daily as high-intensity statin therapy to achieve ≥50% LDL-C reduction and maximize cardiovascular risk reduction. 1
Rationale for High-Intensity Therapy
An 18% 10-year ASCVD risk places this patient in the high-risk category (≥7.5%), where aggressive lipid-lowering provides the greatest absolute benefit. 1
High-intensity statin therapy (rosuvastatin 20 mg or atorvastatin 80 mg daily) reduces major cardiovascular events more effectively than moderate-intensity therapy in high-risk patients. 1
The JUPITER trial demonstrated that rosuvastatin 20 mg daily achieved a median 50% LDL-C reduction and significantly reduced ASCVD events after only 1.9 years in primary prevention patients. 1
Greater LDL-C reduction translates directly to greater cardiovascular benefit—each 38.7 mg/dL reduction in LDL-C produces approximately 20-28% relative risk reduction for cardiovascular events. 1
Dosing Algorithm by Risk Level
For 10-year ASCVD risk ≥20%: Start rosuvastatin 20 mg daily (high-intensity) to achieve maximal risk reduction. 1
For 10-year ASCVD risk 7.5-19.9%: Rosuvastatin 20 mg daily is reasonable when maximal ASCVD risk reduction is desired after risk discussion. 1
For 10-year ASCVD risk <7.5%: Moderate-intensity therapy (rosuvastatin 5-10 mg daily) is typically sufficient. 1
Alternative Moderate-Intensity Approach
If concerns exist about statin tolerance or patient preference favors starting lower:
Rosuvastatin 10 mg daily provides 45-50% LDL-C reduction and represents moderate-to-high intensity therapy. 2, 3
Recent evidence shows rosuvastatin 10 mg plus ezetimibe 10 mg achieves superior LDL-C lowering compared to rosuvastatin 20 mg monotherapy (73% vs 55% achieving LDL-C <70 mg/dL), with lower discontinuation rates (4.8% vs 8.2%). 3, 4
This combination approach may be particularly valuable in elderly patients or those at higher risk for statin intolerance. 4
Important Dosing Considerations
Asian patients: Start at rosuvastatin 5 mg daily due to increased plasma concentrations; do not exceed 20 mg daily. 2
Severe renal impairment (CrCl <30 mL/min): Start at 5 mg daily; do not exceed 10 mg daily. 2
Drug interactions: Multiple medications require dose limitations—cyclosporine limits dosing to 5 mg daily, while teriflunomide, enasidenib, and capmatinib limit dosing to 10 mg daily. 2
Follow-Up and Titration
Assess LDL-C as early as 4 weeks after initiation and adjust dosage if necessary. 2
If LDL-C remains ≥70 mg/dL on maximally tolerated statin therapy, add ezetimibe 10 mg daily (provides additional 15-25% LDL-C reduction). 1, 5
If LDL-C still ≥70 mg/dL after statin plus ezetimibe, consider adding a PCSK9 inhibitor in very high-risk patients. 1, 5
Common Pitfalls to Avoid
Underdosing high-risk patients: An 18% ASCVD risk warrants aggressive therapy—starting with moderate-intensity therapy (rosuvastatin 5-10 mg) leaves significant preventable cardiovascular risk on the table. 1
Ignoring combination therapy: If statin intolerance is a concern, starting rosuvastatin 10 mg with ezetimibe 10 mg achieves better outcomes than rosuvastatin 20 mg alone with fewer side effects. 3, 4
Failing to reassess: Many patients never have follow-up lipid testing to confirm adequate response—check LDL-C at 4-12 weeks to ensure target achievement. 2