Rosuvastatin Dosing for a 59-Year-Old Male with Elevated LDL-C
For a 59-year-old male with elevated LDL-C, initiate rosuvastatin at 10-20 mg daily (moderate-intensity) for primary prevention, or 20-40 mg daily (high-intensity) if he has diabetes, multiple cardiovascular risk factors, or a 10-year ASCVD risk ≥20%. 1
Risk Assessment Determines Intensity
The first step is calculating his 10-year ASCVD risk using the ACC/AHA Pooled Cohort Equations, as treatment decisions should be guided by absolute risk rather than LDL-C levels alone 1, 2:
If 10-year ASCVD risk ≥20%: Start rosuvastatin 20-40 mg daily (high-intensity) to achieve ≥50% LDL-C reduction and target LDL-C <70 mg/dL 1, 3
If 10-year ASCVD risk 7.5-19.9%: Start rosuvastatin 10 mg daily (moderate-intensity), but consider high-intensity (20 mg) if risk-enhancing factors are present (South Asian ancestry, family history of premature ASCVD, chronic kidney disease, metabolic syndrome, inflammatory diseases) 1, 2
If 10-year ASCVD risk <7.5%: Statin therapy generally not indicated unless LDL-C ≥190 mg/dL 1
Special Populations Requiring High-Intensity Therapy
Diabetes: If this patient has diabetes (type 1 or 2), he automatically qualifies for at least moderate-intensity therapy, and high-intensity therapy (rosuvastatin 20-40 mg) is recommended if he has ≥1 additional ASCVD risk factor, targeting LDL-C <70 mg/dL 1. Most diabetic patients aged 40-75 years have ≥7.5% 10-year ASCVD risk 1, 2.
LDL-C ≥190 mg/dL: Start high-intensity rosuvastatin 20-40 mg regardless of other risk factors 3, 2
Specific Dosing Recommendations
The 2025 Diabetes Care guidelines and ACC/AHA define intensity levels as 1, 3:
- High-intensity: Rosuvastatin 20-40 mg daily (achieves 50-63% LDL-C reduction)
- Moderate-intensity: Rosuvastatin 5-10 mg daily (achieves 30-49% LDL-C reduction)
Start with rosuvastatin 10 mg for moderate-intensity or 20 mg for high-intensity therapy 1, 3. The 5 mg dose is reserved for patients with renal impairment, Asian ethnicity, or those requiring dose modifications due to drug interactions 4.
Evidence Supporting This Approach
The JUPITER trial demonstrated that rosuvastatin 20 mg daily achieved 50% LDL-C reduction and significant ASCVD risk reduction in intermediate-risk patients (men ≥50 years, women ≥60 years) after only 1.9 years 1, 2. A subsequent trial showed rosuvastatin 10 mg daily produced significant absolute risk reduction over 5.6 years with acceptable safety 1, 2.
For every 1 mmol/L (39 mg/dL) reduction in LDL-C, relative risk for major coronary events decreases by approximately 25-28%, with no lower threshold beyond which benefit ceases 1.
Monitoring and Titration
Assess LDL-C at 4 weeks after initiation 2, 4. The magnitude of LDL-C reduction achieved determines cardiovascular benefit, so follow-up testing is essential to confirm adherence and adequacy of effect 1, 2.
If LDL-C goal is not achieved on maximum tolerated statin therapy, consider adding ezetimibe or a PCSK9 inhibitor, particularly if LDL-C remains ≥70 mg/dL in high-risk patients 1.
Common Pitfalls to Avoid
- Don't treat based on LDL-C level alone without calculating 10-year ASCVD risk in patients aged 40-75 years 2
- Don't use low-intensity statins (not recommended in this age group) unless the patient is intolerant of higher doses 1
- Don't start at 5 mg unless the patient is Asian, has severe renal impairment (CrCl <30 mL/min), or requires dose modification for drug interactions 4
- Don't forget to assess risk-enhancing factors when 10-year risk is borderline (7.5-10%) or intermediate (10-20%), as these may tip the decision toward high-intensity therapy 1, 2
Safety Considerations
Rosuvastatin has an acceptable safety profile with myopathy incidence <0.1% at recommended doses of 5-40 mg daily 3. There is a slight increased risk of new-onset diabetes, particularly in patients with metabolic syndrome features 3. No clinically significant elevations in AST/ALT >3× ULN or CK >10× ULN were observed in clinical trials 5, 6.