What are the differences between types of statins, such as atorvastatin (Lipitor) and rosuvastatin (Crestor), in terms of efficacy and dosing?

Comparison of Different Statin Types

Rosuvastatin is the most potent statin available, achieving greater LDL-C reduction than atorvastatin at equivalent or even higher doses, with rosuvastatin 10 mg providing similar LDL-C lowering to atorvastatin 20-30 mg and superior efficacy to simvastatin and pravastatin across all dose ranges. 1

Statin Intensity Classification

High-Intensity Statins (≥50% LDL-C Reduction)

• Atorvastatin 40-80 mg reduces LDL-C by approximately 50% 2
• Rosuvastatin 20-40 mg reduces LDL-C by 50-55% on average 2, 3

Moderate-Intensity Statins (30-49% LDL-C Reduction)

• Atorvastatin 10-20 mg 4
• Rosuvastatin 5-10 mg 3, 4
• Simvastatin 20-40 mg 4
• Pravastatin 40-80 mg 4
• Lovastatin 40 mg 4
• Fluvastatin XL 80 mg 4
• Pitavastatin 1-4 mg 4

Direct Comparative Efficacy

Rosuvastatin vs. Atorvastatin Head-to-Head Comparisons

At equivalent doses (1:1 ratio), rosuvastatin demonstrates superior LDL-C lowering:

• Rosuvastatin 10 mg reduces LDL-C by 46% vs. atorvastatin 10 mg at 37% 1
• Rosuvastatin 20 mg reduces LDL-C by 52% vs. atorvastatin 20 mg at 43% 1
• Rosuvastatin 40 mg reduces LDL-C by 55% vs. atorvastatin 40 mg at 48% 1

Rosuvastatin maintains superiority even against double-dose atorvastatin:

• Rosuvastatin 10 mg achieves similar LDL-C reduction to atorvastatin 29 mg 5
• Rosuvastatin 20 mg requires atorvastatin 70 mg for equivalent LDL-C lowering 5
• Rosuvastatin 40 mg achieves greater reduction than the maximum atorvastatin 80 mg dose 5

Rosuvastatin vs. Simvastatin and Pravastatin

Rosuvastatin demonstrates substantially greater potency:

• Rosuvastatin 10 mg reduces LDL-C significantly more than simvastatin 10 mg (46% vs. 28%), 20 mg (35%), or 40 mg (39%) 1
• Rosuvastatin 10 mg requires simvastatin 72 mg for equivalent LDL-C reduction 5
• Rosuvastatin 20 mg achieves greater reduction than simvastatin 80 mg 5
• Rosuvastatin 10 mg reduces LDL-C significantly more than pravastatin 10 mg (20%), 20 mg (24%), or 40 mg (30%) 1

Effects on Other Lipid Parameters

HDL-C Elevation

Rosuvastatin provides superior HDL-C increases compared to other statins:

• Rosuvastatin increases HDL-C by 7.7-9.6% across dose ranges 6
• Atorvastatin increases HDL-C by only 2.1-6.8% 6
• This HDL-C benefit is consistent across all rosuvastatin doses 1

Small Dense LDL-C Reduction

Rosuvastatin at maximum dose reduces small dense LDL-C more effectively:

• Rosuvastatin 40 mg reduces sdLDL-C by 53% vs. atorvastatin 80 mg at 46% (p<0.01) 7
• This represents superior modification of the most atherogenic LDL particles 7

Non-HDL-C and Apolipoprotein B

Rosuvastatin achieves greater reductions in atherogenic particle measures:

• Rosuvastatin reduces non-HDL-C by 51% vs. atorvastatin at 48% 1
• Total cholesterol/HDL-C ratio decreases by 46% with rosuvastatin vs. 39% with atorvastatin 7

Triglyceride Effects

Both rosuvastatin and atorvastatin provide similar triglyceride lowering:

• Rosuvastatin reduces triglycerides by 24-28% 1, 7
• Atorvastatin reduces triglycerides by 26% 7
• Both are superior to simvastatin and pravastatin for triglyceride reduction 6

Clinical Outcomes Data

Cardiovascular Event Reduction

Rosuvastatin 20 mg demonstrated significant cardiovascular benefit in the JUPITER trial:

• 44% relative risk reduction in major CV events (p<0.001) 1
• Significant reductions in nonfatal MI, nonfatal stroke, and arterial revascularization procedures 1
• Absolute risk reduction of 1.2% over 2 years 1

High-intensity statin therapy (atorvastatin 80 mg or rosuvastatin 20 mg) reduces ASCVD events more than moderate-intensity therapy in secondary prevention: 2

Safety Profile Comparison

Adverse Event Rates

Meta-analysis of head-to-head trials shows no significant safety differences:

• No significant differences in myalgia rates between rosuvastatin and atorvastatin at any dose ratio 8
• No significant differences in ALT elevation >3x ULN 8
• No significant differences in CK elevation >10x ULN 8
• No significant differences in deaths, serious adverse events, or withdrawals due to adverse events 8

Myopathy Risk

Both high-intensity statins carry low myopathy risk:

• Rosuvastatin myopathy incidence <0.1% at recommended doses of 5-40 mg 3
• Drug tolerability was similar across all statins in comparative trials 6

Diabetes Risk

High-intensity statins may increase new-onset diabetes risk more than moderate-intensity:

• High-intensity statins show 36% relative increase in diabetes risk vs. 10% with moderate-intensity 4
• This risk is particularly relevant in patients with metabolic syndrome features 3

Clinical Decision Algorithm

For Secondary Prevention (Clinical ASCVD)

In patients ≤75 years old:

• First choice: Atorvastatin 80 mg or rosuvastatin 20 mg (high-intensity) 2
• If high-intensity contraindicated or not tolerated: Moderate-intensity statin (atorvastatin 10-20 mg or rosuvastatin 5-10 mg) 2

In patients >75 years old:

• Preferred: Moderate-intensity statin therapy (rosuvastatin 5-10 mg or atorvastatin 10-20 mg) 2, 3
• High-intensity may be considered in very healthy older adults, but evidence is limited 2

For Primary Prevention

Diabetes patients aged 40-75 without additional ASCVD risk factors:

• Recommended: Moderate-intensity statin (rosuvastatin 5-10 mg or atorvastatin 10-20 mg) 3, 4

Diabetes patients with additional ASCVD risk factors:

• Recommended: High-intensity statin (rosuvastatin 20-40 mg or atorvastatin 40-80 mg) 9

LDL-C ≥190 mg/dL:

• Recommended: High-intensity statin (rosuvastatin 20-40 mg or atorvastatin 40-80 mg) 3

Practical Dosing Equivalencies

To achieve approximately 45% LDL-C reduction:

• Rosuvastatin 10 mg 1
• Atorvastatin 29 mg (use 20-40 mg in practice) 5
• Simvastatin 72 mg (not achievable with standard dosing) 5

To achieve approximately 50% LDL-C reduction:

• Rosuvastatin 20 mg 1
• Atorvastatin 70 mg (use 80 mg in practice) 5
• Simvastatin >80 mg (not achievable) 5

To achieve approximately 55% LDL-C reduction:

• Rosuvastatin 40 mg 1
• Not achievable with maximum doses of atorvastatin or simvastatin 5

Key Clinical Pitfalls to Avoid

Do not assume all statins are equivalent at the same milligram dose - rosuvastatin is 3-3.5 times more potent than atorvastatin and 7-8 times more potent than simvastatin on a milligram basis 5

Do not automatically escalate to high-intensity statins in patients >75 years - moderate-intensity therapy is preferred unless they have established ASCVD and are very healthy 2, 3

Do not overlook the superior HDL-C raising effects of rosuvastatin - this may provide additional cardiovascular benefit beyond LDL-C lowering 6

Do not use atorvastatin 40 mg expecting high-intensity effects - this dose was only used in one RCT when atorvastatin 80 mg was not tolerated, and whether to uptitrate should be based on individual risk-benefit assessment 2