Rosuvastatin 10mg Daily is the Most Appropriate Statin for This Patient
For this patient on darunavir/cobicistat, rosuvastatin 10mg daily (Option C) is the most appropriate choice, as it provides moderate-intensity statin therapy with acceptable drug-drug interactions and appropriate dosing for protease inhibitor co-administration. 1
Rationale Based on Current Guidelines
The 2025 International Antiviral Society-USA Panel guidelines specifically recommend moderate-intensity doses of rosuvastatin (10mg) or atorvastatin (20mg) as acceptable substitutes for pitavastatin in people with HIV requiring statin therapy. 1 Since pitavastatin is not covered by this patient's insurance, rosuvastatin 10mg represents the guideline-endorsed alternative.
Drug-Drug Interaction Analysis
Why Each Option is Appropriate or Inappropriate:
Simvastatin (Option A) - CONTRAINDICATED:
- Simvastatin is absolutely contraindicated with protease inhibitors, including darunavir/cobicistat, as they greatly increase simvastatin's AUC, leading to severe risk of myopathy and rhabdomyolysis. 1, 2
- This option must be eliminated immediately due to safety concerns.
Atorvastatin 40mg (Option B) - INAPPROPRIATE DOSE:
- While atorvastatin is acceptable with protease inhibitors, it requires caution and the lowest starting dose due to moderate increases in atorvastatin's AUC when combined with protease inhibitors. 1
- The 2025 guidelines recommend atorvastatin 20mg (not 40mg) as the moderate-intensity dose appropriate for this indication. 1
- Starting at 40mg with darunavir/cobicistat would represent excessive exposure and increased toxicity risk.
Rosuvastatin 10mg (Option C) - CORRECT CHOICE:
- Rosuvastatin is acceptable with appropriate dosing and monitoring when combined with protease inhibitors. 1
- The 10mg dose represents the guideline-recommended moderate-intensity dose for HIV patients requiring statin therapy. 1
- Lopinavir/ritonavir and tipranavir increase rosuvastatin's AUC, but darunavir/cobicistat has a more favorable interaction profile. 1
- Rosuvastatin was found superior to pravastatin in HIV patients in comparative studies. 1
Pravastatin 40mg (Option D) - PROBLEMATIC WITH DARUNAVIR:
- While pravastatin is generally acceptable with most protease inhibitors, there is a critical exception with darunavir, which increases pravastatin's AUC by 81%. 1
- The guidelines specifically state pravastatin is "acceptable with appropriate dosing and monitoring, except with darunavir." 1
- This patient is specifically on darunavir/cobicistat, making pravastatin a suboptimal choice.
Clinical Context from REPRIEVE Trial
This 59-year-old patient with long-standing HIV (since 1991) is an ideal candidate for statin therapy based on the REPRIEVE trial, which demonstrated a 36% reduction in major adverse cardiovascular events with moderate-intensity statin therapy in people with HIV aged 40-75 years. 1
Critical Monitoring Considerations
When prescribing rosuvastatin with darunavir/cobicistat:
- Monitor for muscle symptoms and check creatine kinase if symptoms develop. 3
- Baseline and periodic liver function tests should be considered due to potential hepatotoxicity with increased statin concentrations. 3
- The patient should be counseled on signs of statin toxicity, including muscle pain, weakness, and dark urine. 3
Common Pitfalls to Avoid
- Never use simvastatin or lovastatin with any boosted protease inhibitor or cobicistat-containing regimen—this is an absolute contraindication. 1, 2
- Do not assume all statins interact equally with antiretrovirals; the interaction severity varies dramatically based on metabolic pathways. 2
- Avoid starting atorvastatin at higher doses (>20mg) when combined with protease inhibitors due to increased drug exposure. 1
- Remember the specific darunavir-pravastatin interaction that makes pravastatin less favorable despite its generally good profile with other protease inhibitors. 1