What is the treatment plan for high cholesterol using Crestor (rosuvastatin)?

Treatment Plan for High Cholesterol Using Crestor (Rosuvastatin)

Initiate rosuvastatin at 5-40 mg once daily based on your cardiovascular risk category, with the goal of achieving at least a 30-50% LDL-C reduction and targeting LDL-C <70 mg/dL for high-risk patients or <100 mg/dL for moderate-risk patients. 1

Risk Stratification Determines Starting Dose

Your rosuvastatin dose depends on which of four evidence-based treatment categories you fall into:

Secondary Prevention (Established Heart Disease)

• Start rosuvastatin 20-40 mg daily (high-intensity statin) 1
• Target: LDL-C <70 mg/dL, ideally <55 mg/dL if very high risk 2, 3
• Expected LDL-C reduction: 52-63% 2, 4

Primary Prevention with LDL-C ≥190 mg/dL

• Start rosuvastatin 20-40 mg daily (high-intensity statin) 1
• Target: At least 50% LDL-C reduction from baseline 1, 2
• This includes patients with familial hypercholesterolemia 1, 5

Diabetes Mellitus (Ages 40-75, LDL-C 70-189 mg/dL)

• Start rosuvastatin 10-20 mg daily (moderate to high-intensity) 1
• Target: LDL-C <100 mg/dL for primary prevention, <70 mg/dL if additional risk factors present 6, 3
• All diabetic patients in this age range require statin therapy regardless of baseline LDL-C 1, 3

Primary Prevention Based on 10-Year ASCVD Risk

• If 10-year risk ≥7.5%: Start rosuvastatin 10-20 mg daily 1
• If 10-year risk 5-7.4%: Consider rosuvastatin 5-10 mg daily after shared decision-making 1
• If 10-year risk <5%: Lifestyle modification preferred; statin optional based on additional risk factors 1
• Use ACC/AHA Pooled Cohort Equations to calculate 10-year risk 1

Dosing Specifications

Standard dosing regimen:

• Take rosuvastatin once daily, with or without food, at any time of day 5
• Swallow tablets whole 5
• Available doses: 5 mg, 10 mg, 20 mg, 40 mg 5

Dose intensity classifications:

• High-intensity (≥50% LDL-C reduction): rosuvastatin 20-40 mg 1
• Moderate-intensity (30-49% LDL-C reduction): rosuvastatin 5-10 mg 1

Special Population Adjustments

Asian patients:

• Start at 5 mg daily due to increased drug exposure 5
• Consider risks/benefits if doses >20 mg needed 5

Severe renal impairment (CrCl <30 mL/min, not on dialysis):

• Start at 5 mg daily, do not exceed 10 mg daily 5

Pediatric patients with familial hypercholesterolemia:

• Ages 8-10 years: 5-10 mg daily 5
• Ages ≥10 years: 5-20 mg daily 5
• Homozygous familial hypercholesterolemia ≥7 years: 20 mg daily 5

Monitoring and Titration Strategy

Initial monitoring:

• Recheck lipid panel 4-6 weeks after starting therapy 2, 6, 5
• Assess adherence, therapeutic response, and safety 1

Treatment goals:

• LDL-C reduction of at least 30-40% for moderate-risk patients 6, 3
• LDL-C reduction of ≥50% for high-risk patients 1, 2
• Non-HDL-C <100 mg/dL for high-risk patients 2

If goals not achieved on initial dose:

• Increase rosuvastatin to next higher dose (maximum 40 mg) 2, 6
• Add ezetimibe 10 mg for additional 20-25% LDL-C reduction 2, 3
• The combination of rosuvastatin plus ezetimibe produces greater LDL-C reductions with fewer side effects than high-dose statin monotherapy 2

Escalation for Inadequate Response

If LDL-C goals not met on maximally tolerated rosuvastatin plus ezetimibe:

• Refer to lipid specialist for consideration of PCSK9 inhibitors (additional 60% LDL-C reduction) or bempedoic acid 2, 3

Safety Considerations

Common adverse effects (≥2% incidence):

• Headache, nausea, myalgia, asthenia, constipation 5
• These occur at similar rates to placebo in controlled trials 1, 3

Serious adverse effects (rare):

• Myopathy/rhabdomyolysis: Extremely rare with modern statins 3, 7
• Elevated liver enzymes: 0.5-2% incidence, dose-dependent 3
• No consistent pattern of renal failure despite mild transient proteinuria 7

Risk factors for myopathy:

• Age ≥65 years, uncontrolled hypothyroidism, renal impairment, higher doses, certain drug interactions 5

Patient instructions:

• Report unexplained muscle pain, tenderness, or weakness, especially with fever or malaise 5
• If taking aluminum/magnesium antacids, take rosuvastatin at least 2 hours before the antacid 5

Drug interactions requiring dose limits:

• Cyclosporine: Do not exceed rosuvastatin 5 mg daily 5
• Teriflunomide, enasidenib, capmatinib: Do not exceed 10 mg daily 5
• Fostamatinib: Do not exceed 20 mg daily 5

Critical Clinical Pearls

The 2013 ACC/AHA guidelines shifted away from "treat-to-target" LDL-C goals to fixed-dose statin intensity based on risk category 1. However, the 2019 guidelines acknowledge that maximal ASCVD risk reduction may justify targeting specific LDL-C thresholds, especially when 10-year risk ≥20% 1. In practice, use statin intensity as the primary guide, but monitor LDL-C levels to ensure adequate response and adherence 1, 2.

Rosuvastatin is the most potent statin available, producing 4.5% additional LDL-C reduction for each doubling of dose 8. Approximately 90% of LDL-C reduction occurs within the first 2 weeks of treatment 8. This allows earlier goal achievement and may help avoid combination therapy in many patients 9, 4.

Do not discontinue rosuvastatin if LDL-C goal is not reached on maximum tolerated dose—the cardiovascular benefit comes from the absolute LDL-C reduction achieved, not from hitting an arbitrary target 1, 3. Patients with familial hypercholesterolemia who achieve only 120 mg/dL LDL-C on triple therapy have still reduced their LDL-C by >50% from baseline and derive substantial benefit 1.