From the Guidelines
Statin therapy is recommended for patients with clinical atherosclerotic cardiovascular disease (ASCVD), with high-intensity statin therapy initiated or continued in patients 75 years of age or younger, aiming for a 50% or greater reduction in LDL-C levels. This recommendation is based on the 2019 American College of Cardiology/American Heart Association guideline on the management of blood cholesterol 1. The guideline suggests that in patients with clinical ASCVD, high-intensity statin therapy should be initiated or continued, with the aim of achieving a 50% or greater reduction in LDL-C levels.
Key Recommendations
- In patients with clinical ASCVD who are 75 years of age or younger, high-intensity statin therapy should be initiated or continued with the aim of achieving a 50% or greater reduction in LDL-C levels 1.
- In patients with clinical ASCVD in whom high-intensity statin therapy is contraindicated or who experience statin-associated side effects, moderate-intensity statin therapy should be initiated or continued with the aim of achieving a 30% to 49% reduction in LDL-C levels 1.
- In patients with clinical ASCVD who are judged to be very high risk and considered for PCSK9 inhibitor therapy, maximally tolerated LDL-C lowering therapy should include maximally tolerated statin therapy and ezetimibe 1.
Additional Considerations
- 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 1.
- The 2022 Diabetes Care guideline also recommends high-intensity statin therapy for patients with diabetes and atherosclerotic cardiovascular disease, with consideration of adding additional LDL-lowering therapy if LDL cholesterol is $70 mg/dL on maximally tolerated statin dose 1.
Monitoring and Follow-up
- Patients should be monitored with lipid panels and liver function tests at baseline, 4-12 weeks after initiation, and then annually.
- Statins work by inhibiting HMG-CoA reductase, the rate-limiting enzyme in cholesterol synthesis, thereby reducing LDL cholesterol production in the liver and increasing LDL receptor expression, which enhances clearance of LDL from the bloodstream.
From the FDA Drug Label
ROSUVASTATIN tablets, for oral use Rosuvastatin tablets are an HMG Co-A reductase inhibitor (statin) indicated: To reduce the risk of major adverse cardiovascular (CV) events (CV death, nonfatal myocardial infarction, nonfatal stroke, or an arterial revascularization procedure) in adults without established coronary heart disease who are at increased risk of CV disease based on age, high-sensitivity C-reactive protein (hsCRP) ≥2 mg/L, and at least one additional CV risk factor. As an adjunct to diet to: reduce LDL-C in adults with primary hyperlipidemia.
The recommended statin dosage for adults is 5 mg to 40 mg once daily 2.
- The dosage for pediatric patients with HeFH is 5 mg to 10 mg once daily for patients aged 8 to less than 10 years of age, and 5 mg to 20 mg once daily for patients aged 10 years and older.
- The dosage for pediatric patients with HoFH is 20 mg once daily for patients aged 7 years and older.
- For Asian patients, the recommended initial dosage is 5 mg once daily.
- For patients with severe renal impairment, the initial dosage is 5 mg once daily, and should not exceed 10 mg once daily.
From the Research
Statin Recommendations
- High-intensity statin therapy is recommended for patients with clinical atherosclerotic cardiovascular disease (ASCVD) or at high risk of ASCVD 3.
- The choice of statin depends on the patient's risk profile and the potential for adverse drug reactions (ADRs) 4.
- Atorvastatin and rosuvastatin are two commonly used high-intensity statins, with atorvastatin associated with a higher incidence of ADRs compared to rosuvastatin 4.
- Ezetimibe can be added to statin therapy to achieve greater low-density lipoprotein cholesterol (LDL-C) reductions and improve goal attainment in high-risk patients 5, 6.
Patient Selection
- High-risk patients who may benefit from high-intensity statin therapy include those with severe hypercholesterolemia, diabetes with associated risk factors, and patients aged 40 to 75 years with a 10-year risk for ASCVD of 20% or greater 3.
- Patients with a 10-year risk of 7.5% to less than 20% may benefit from coronary artery calcium scoring to determine their risk profile 3.
Combination Therapy
- Adding ezetimibe to statin therapy can provide additional LDL-C lowering and ASCVD risk reduction, with a relatively safe profile 6, 7.
- Combination therapy with ezetimibe and a moderate-intensity statin may be considered for patients who cannot tolerate high-intensity statin therapy 3.
- The choice of combination therapy should be individualized based on the patient's risk profile and potential for adverse effects 6.