Difference Between Crestor (Rosuvastatin) and Lipitor (Atorvastatin)
Both Crestor (rosuvastatin) and Lipitor (atorvastatin) are high-intensity statins that effectively reduce cardiovascular events, but rosuvastatin is more potent milligram-for-milligram, achieving greater LDL-C reductions at lower doses compared to atorvastatin. 1, 2
Comparative Potency and LDL-C Reduction
Rosuvastatin 10 mg produces approximately 44-47% LDL-C reduction, which is equivalent to or greater than atorvastatin 20 mg (30-43% reduction). 1, 3
Rosuvastatin 20 mg achieves approximately 52-55% LDL-C reduction, comparable to atorvastatin 40-80 mg. 4, 5
Atorvastatin demonstrates dose-dependent LDL-C reductions: 10 mg (35-40%), 20 mg (43-47%), 40 mg (47-50%), and 80 mg (50-52%). 4, 6
At maximum doses, rosuvastatin 80 mg produces 60% LDL-C reduction compared to 52% with atorvastatin 80 mg. 7
Effects on Other Lipid Parameters
Rosuvastatin produces significantly greater HDL-C increases compared to atorvastatin at equivalent doses (up to 14% increase vs. 3-6%), which may provide additional cardiovascular benefit. 5, 1
Both agents reduce triglycerides dose-dependently (13-28% reduction), with similar efficacy at comparable intensity levels. 4, 5
Rosuvastatin achieves more favorable improvements in total cholesterol, non-HDL-C, apolipoprotein B, and lipid ratios compared to atorvastatin at equivalent LDL-C lowering doses. 2, 7
Goal Achievement Rates
Significantly more patients achieve NCEP ATP III LDL-C goals (<100 mg/dL) with rosuvastatin compared to atorvastatin at equivalent starting doses (68.8% vs. 62.5% with rosuvastatin 10 mg vs. atorvastatin 20 mg). 1
When force-titrated across their dose ranges, rosuvastatin enables more high-risk patients to achieve the very high-risk LDL-C goal of <70 mg/dL compared to atorvastatin. 2
Guideline-Based Statin Intensity Classification
The American College of Cardiology/American Heart Association classifies high-intensity statin therapy as achieving ≥50% LDL-C reduction, which includes rosuvastatin 20-40 mg and atorvastatin 40-80 mg. 4, 5
Moderate-intensity therapy (30-49% LDL-C reduction) includes rosuvastatin 5-10 mg and atorvastatin 10-20 mg. 5
Current guidelines recommend fixed-dose statin intensity based on cardiovascular risk category rather than titrating to specific LDL-C targets. 4
Safety and Tolerability Profile
Both agents demonstrate similar safety profiles at their respective high-intensity doses, with myalgia, elevated liver enzymes (ALT >3x upper limit in 1-3% of patients), and new-onset diabetes (approximately 0.2% per year) being the primary concerns. 4, 1
No significant differences in adverse event rates exist between rosuvastatin and atorvastatin when compared at equivalent LDL-C lowering doses (approximately 27% vs. 26% adverse event incidence). 1
Rhabdomyolysis risk is extremely low with both agents when used as monotherapy, though gemfibrozil combination should be avoided with both statins. 4, 1
Renal Dosing Considerations
For patients with severe renal impairment (CrCl <30 mL/min), atorvastatin is preferred as it requires no dose adjustment, while rosuvastatin should not exceed 10 mg daily in this population. 5
Rosuvastatin requires dose adjustment in patients with significant renal dysfunction, whereas atorvastatin provides more flexible dosing without renal adjustment. 5
Clinical Decision-Making Algorithm
For high-risk patients requiring ≥50% LDL-C reduction, start with either rosuvastatin 20 mg or atorvastatin 40-80 mg as both are classified as high-intensity therapy. 4
If choosing rosuvastatin, 20 mg provides high-intensity therapy with excellent tolerability; if choosing atorvastatin, 40-80 mg provides equivalent high-intensity therapy. 4
Consider rosuvastatin when greater HDL-C elevation is desired or when lower pill burden is preferred (lower milligram dose for equivalent effect). 5, 1
Consider atorvastatin in patients with severe renal impairment (CrCl <30 mL/min) due to more flexible dosing without mandatory renal adjustment. 5
Cost-Effectiveness Considerations
- Rosuvastatin 10 mg has demonstrated cost-effectiveness compared to atorvastatin 20 mg in both US and UK healthcare settings, primarily due to superior goal achievement rates. 1
Important Clinical Caveats
Treatment decisions should be based on comprehensive cardiovascular risk assessment using validated tools (ACC/AHA Pooled Cohort Equations) rather than isolated cholesterol values alone. 8, 4
For patients with 10-year ASCVD risk ≥7.5%, moderate- to high-intensity statin therapy is recommended regardless of which specific agent is chosen. 8, 4
Monitor liver enzymes at baseline and as clinically indicated, assess for muscle symptoms regularly, and counsel patients about the small increased risk of new-onset diabetes with both agents. 4
If LDL-C goals are not achieved with maximally tolerated statin monotherapy, add ezetimibe 10 mg daily (provides additional 15-25% LDL-C reduction) before considering PCSK9 inhibitors. 4