What is the starting dose of rosuvastatin (Crestor) for patients with hyperlipidemia?

Starting Dose of Rosuvastatin

The standard starting dose of rosuvastatin is 10 mg once daily for most patients with hyperlipidemia, with a lower starting dose of 5 mg recommended for Asian patients due to higher plasma levels. 1

Standard Dosing by Patient Population

Non-Asian Adults

• Start with rosuvastatin 10 mg once daily for most patients with primary hyperlipidemia or mixed dyslipidemia 2, 3
• This dose achieves approximately 45-52% reduction in LDL-C from baseline 2, 4
• The 10 mg dose enables most patients to reach National Cholesterol Education Program LDL-C goals 4, 5

Asian Patients (Critical Distinction)

• Start with rosuvastatin 5 mg once daily in patients of Asian descent (Japanese, Chinese, Malay, and Asian Indian) 1
• The FDA specifically recommends this lower starting dose due to approximately 2-fold higher rosuvastatin plasma levels compared to Caucasian patients 1
• Asian patients demonstrate similar LDL-C reductions at lower doses compared to non-Asian patients, with 5 mg producing 42-52% LDL-C reduction 6
• Exercise caution when uptitrating doses in Asian patients 1

Intensity-Based Dosing Strategy

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

• Rosuvastatin 5-10 mg daily is classified as moderate-intensity statin therapy 1, 7
• Appropriate for primary prevention in adults aged 40-75 years with diabetes and no additional ASCVD risk factors 1
• Suitable for intermediate-risk patients without established cardiovascular disease 1

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

• Rosuvastatin 20-40 mg daily achieves high-intensity statin therapy 1, 7
• Reserved for patients with established ASCVD, LDL-C ≥190 mg/dL, or diabetes with additional ASCVD risk factors 1
• The 20 mg dose was used in the JUPITER trial, demonstrating 44% relative risk reduction in major cardiovascular events 2

Dose Titration Algorithm

Follow this stepwise approach:

1. Initial Assessment: Determine patient ethnicity, baseline LDL-C, and cardiovascular risk 1

2. Starting Dose Selection:

   • Asian patients: 5 mg daily 1
   • Non-Asian patients with moderate risk: 10 mg daily 2, 3
   • Non-Asian patients requiring high-intensity therapy: Consider starting at 20 mg daily 7, 2

3. Monitoring: Check lipid panel at 4-12 weeks after initiation 8

4. Titration: If LDL-C goal not achieved, increase dose incrementally (5 mg → 10 mg → 20 mg → 40 mg maximum) 2

Special Populations and Dose Adjustments

Renal Impairment

• Do not exceed 10 mg daily in patients with severe renal impairment (CrCl <30 mL/min) 8
• Consider alternative statins like atorvastatin for patients with significant renal dysfunction requiring higher intensity therapy 8

Drug Interactions

• Maximum dose 5 mg daily when co-administered with cyclosporine, tacrolimus, everolimus, or sirolimus due to 7-fold increase in rosuvastatin exposure 7
• When used with resmetirom for MASH/NASH, limit rosuvastatin to 20 mg daily 7

Age Considerations

• Patients >75 years: Consider moderate-intensity therapy (5-10 mg) rather than high-intensity dosing, as additional benefit from high-intensity therapy is unclear in this age group 7
• For patients already on statin therapy at age >75 years, continuation is reasonable 1

Common Pitfalls to Avoid

• Failing to adjust starting dose for Asian ethnicity: This increases risk of myopathy and adverse effects due to higher drug exposure 1
• Starting too high in statin-naive patients: Begin with 10 mg (or 5 mg in Asians) and titrate based on response rather than starting at maximum doses 2, 3
• Ignoring renal function: Severe renal impairment requires dose limitation to prevent toxicity 8
• Not monitoring after initiation: Lipid levels should be checked 4-12 weeks after starting to assess efficacy and guide dose adjustments 8