What statin medication and dose should I start a patient with high cholesterol or at risk for cardiovascular disease on?

Statin Selection and Dosing for Cardiovascular Risk Reduction

For most patients with high cholesterol or cardiovascular risk, start with moderate-intensity statin therapy using atorvastatin 10-20 mg or rosuvastatin 5-10 mg once daily, escalating to high-intensity therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) for patients with established atherosclerotic cardiovascular disease or diabetes with multiple risk factors. 1

Primary Decision Algorithm: Risk Stratification First

Your statin choice depends entirely on whether the patient has established atherosclerotic cardiovascular disease (ASCVD):

Patients WITH Established ASCVD (Secondary Prevention)

Start high-intensity statin therapy immediately to achieve ≥50% LDL cholesterol reduction: 1

• Atorvastatin 40-80 mg once daily, OR 1
• Rosuvastatin 20-40 mg once daily 1

High-intensity therapy reduces cardiovascular events by approximately 21-25% per 39 mg/dL LDL reduction in patients with coronary heart disease, stroke, TIA, or peripheral arterial disease. 1 The evidence shows rosuvastatin 20-40 mg achieves ≥50% LDL reduction in 57-71% of patients, compared to only 40-59% with atorvastatin 40-80 mg. 2

Target LDL cholesterol <70 mg/dL; if not achieved on maximum tolerated statin, add ezetimibe. 1

Patients WITHOUT Established ASCVD (Primary Prevention)

Start moderate-intensity statin therapy for most patients aged 40-75 years with cardiovascular risk factors (diabetes, hypertension, dyslipidemia, smoking): 1

• Atorvastatin 10-20 mg once daily, OR 1
• Rosuvastatin 5-10 mg once daily, OR 1
• Simvastatin 20-40 mg once daily, OR 1
• Pravastatin 40-80 mg once daily 1

These regimens achieve 30-49% LDL cholesterol reduction. 3

Escalate to high-intensity therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) if: 1

• Age 50-70 years with multiple ASCVD risk factors, OR
• 10-year ASCVD risk ≥20%, OR
• Diabetes with additional ASCVD risk factors

Specific Clinical Scenarios

Diabetes Patients (Age 40-75 Years)

Start moderate-intensity statin regardless of baseline LDL cholesterol level—diabetes itself mandates therapy. 4 Do not delay treatment waiting for elevated LDL; multiple trials demonstrate 9% reduction in all-cause mortality and 13% reduction in vascular mortality for each 39 mg/dL LDL reduction. 1, 4

Upgrade to high-intensity therapy if the patient has: 1

• Established ASCVD, OR
• Multiple additional ASCVD risk factors, OR
• Age 50-70 years

Young Adults (Age 20-39 Years)

Consider moderate-intensity statin therapy only if additional ASCVD risk factors are present (family history, smoking, hypertension, severe dyslipidemia). 1 Evidence is limited in this age group.

Older Adults (Age >75 Years)

Continue existing statin therapy; benefits persist with similar relative risk reduction as younger patients. 1 However, do not escalate from moderate to high-intensity therapy based solely on age, as more intensive therapy did not show additional benefit in those >75 years with established ASCVD. 1

For statin-naive patients >75 years, the evidence is insufficient to recommend routine initiation. 5

Critical Dosing Distinctions to Avoid Errors

Common pitfall: Prescribing rosuvastatin 10 mg as "high-intensity" therapy—this is moderate-intensity and achieves only 30-49% LDL reduction. 6 High-intensity requires rosuvastatin 20-40 mg to achieve ≥50% reduction. 1, 6

Fluvastatin is never high-intensity: Even fluvastatin XL 80 mg achieves only moderate-intensity LDL reduction (30-49%). 1, 7

Managing Statin Intolerance

If myalgias or side effects occur: 1, 8

1. Try a different statin (fluvastatin or pravastatin are better tolerated), starting low and titrating up 8
2. Use alternate-day dosing with rosuvastatin or atorvastatin 8
3. Combine lowest tolerated statin dose with ezetimibe to reach LDL goals 1, 8

Evidence demonstrates cardiovascular benefit even with extremely low, less-than-daily statin doses—do not discontinue entirely. 1

If creatine kinase (CK) >5× upper limit of normal or severe symptoms occur, stop the statin immediately. 8 Once asymptomatic and CK normalizes, restart with an alternative approach above.

Monitoring Protocol

• Obtain lipid panel 4-12 weeks after initiation to assess response and medication adherence 3, 4
• Target 30-49% LDL reduction with moderate-intensity therapy 1
• Target ≥50% LDL reduction with high-intensity therapy 1
• Continue annual lipid monitoring thereafter 4

If LDL goals are not met despite documented adherence, add ezetimibe (preferred due to lower cost) or consider PCSK9 inhibitors for very high-risk patients. 1

Drug Interactions Requiring Dose Adjustment

Limit fluvastatin to 20 mg daily when combined with: 7

• Cyclosporine
• Fluconazole

Monitor closely when statins are combined with: 7

• Fibrates (increased myopathy risk)
• Niacin ≥1 g/day (increased myopathy risk)
• Warfarin (monitor INR when starting/stopping statin)
• Glyburide (monitor glucose)
• Phenytoin (monitor drug levels)

Renal Impairment Considerations

For patients with impaired renal function, moderate-intensity therapy (atorvastatin 10-20 mg, rosuvastatin 5-10 mg, pravastatin 40-80 mg, or fluvastatin XL 80 mg) is appropriate, with dose adjustments required for severe renal impairment. 3