What is the starting dose of rosuvastatin (Crestor) for an adult patient with hypercholesterolemia or at risk for cardiovascular disease?

Starting Dose of Rosuvastatin

The standard starting dose of rosuvastatin is 10 mg once daily for most adult patients with hypercholesterolemia, though 5 mg once daily is recommended for Asian patients and those with severe renal impairment. 1

Standard Dosing for General Population

• Rosuvastatin 10 mg once daily is the typical starting dose for adults with hypercholesterolemia or cardiovascular risk factors, which reduces LDL-C by approximately 50% from baseline 2
• The FDA-approved dosage range is 5-40 mg orally once daily, with the specific dose depending on the patient's indication, baseline LDL-C level, and cardiovascular risk 1
• Rosuvastatin can be taken at any time of day, with or without food 1

Intensity Classification by Dose

• Rosuvastatin 5-10 mg daily is classified as moderate-intensity statin therapy (achieving 30-49% LDL-C reduction) 3
• Rosuvastatin 20-40 mg daily is classified as high-intensity statin therapy (achieving ≥50% LDL-C reduction) 3
• For primary prevention in adults aged 40-75 years, low to moderate doses (5-10 mg) are typically used based on cardiovascular risk assessment 4

Special Population Considerations

Asian Patients

• Asian patients should start at 5 mg once daily due to significantly higher rosuvastatin plasma concentrations compared to white patients 1
• The FDA specifically recommends this lower starting dose for Japanese, Chinese, Malay, and Asian Indian patients 4
• Consider risks and benefits carefully when uptitrating Asian patients beyond 20 mg daily 1

Severe Renal Impairment

• Patients with severe renal impairment (CrCl <30 mL/min/1.73 m²) not on hemodialysis should start at 5 mg once daily and not exceed 10 mg daily 1
• No dose adjustment is needed for mild to moderate renal impairment 1

Pediatric Patients

• For children aged 8 to <10 years with heterozygous familial hypercholesterolemia: start with 5-10 mg once daily 1
• For children aged ≥10 years with heterozygous familial hypercholesterolemia: start with 5-20 mg once daily 1
• For children aged ≥7 years with homozygous familial hypercholesterolemia: 20 mg once daily 1

Clinical Scenarios Requiring Higher Starting Doses

• Patients with LDL-C ≥190 mg/dL should receive high-intensity therapy (20-40 mg) regardless of other risk factors 3
• Adults ≤75 years with established ASCVD (acute coronary syndrome, MI, stroke, TIA, peripheral arterial disease) should start high-intensity therapy (20-40 mg) 3
• Very high-risk patients with multiple major risk factors may benefit from starting at higher doses to achieve LDL-C <70 mg/dL 3

Drug Interaction Considerations

When prescribing rosuvastatin, several important drug interactions require dose limitations 1:

• With cyclosporine: do not exceed 5 mg once daily (7-fold increase in rosuvastatin exposure) 1
• With teriflunomide, enasidenib, or capmatinib: do not exceed 10 mg once daily 1
• With fostamatinib or febuxostat: do not exceed 20 mg once daily 1
• Avoid concomitant use with gemfibrozil; if necessary, start at 5 mg and do not exceed 10 mg daily 1

Monitoring and Titration

• Assess LDL-C as early as 4 weeks after initiating therapy and adjust dosage as needed 1
• The dose can be uptitrated based on LDL-C response and treatment goals 1
• Most patients achieve their NCEP ATP III LDL-C goals with the starting dose of 10 mg 5

Common Pitfall to Avoid

Do not automatically start all patients at 10 mg without considering ethnicity and renal function—Asian patients and those with severe renal impairment require the lower 5 mg starting dose to avoid excessive drug exposure and increased risk of myopathy 4, 1