What is the recommended dosage of rosuvastatin for an adult patient with hypercholesterolemia (high cholesterol) or at risk for cardiovascular disease, considering factors such as impaired renal function and liver disease?

Rosuvastatin Dosing for Hypercholesterolemia and Cardiovascular Risk

For most adult patients with hypercholesterolemia or cardiovascular disease risk, initiate rosuvastatin at 10-20 mg once daily, with the dose range extending from 5-40 mg depending on LDL-C goals, cardiovascular risk stratification, renal function, ethnicity, and drug interactions. 1, 2

Standard Dosing by Indication

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

• Rosuvastatin 20-40 mg daily is classified as high-intensity statin therapy for patients with established ASCVD (acute coronary syndromes, MI, stable/unstable angina, coronary revascularization, stroke, TIA, or peripheral arterial disease) who are ≤75 years old 1
• Patients with LDL-C ≥190 mg/dL should receive high-intensity rosuvastatin (20-40 mg) regardless of other risk factors 1
• Very high-risk patients with multiple major risk factors, diabetes, severe uncontrolled risk factors, or metabolic syndrome benefit from intensive LDL lowering to <70 mg/dL using rosuvastatin 20-40 mg 1

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

• Rosuvastatin 5-10 mg daily achieves moderate-intensity LDL-C reduction for primary prevention in adults aged 40-75 years based on cardiovascular risk assessment 1
• Patients >75 years with ASCVD should receive moderate-intensity therapy (5-10 mg) as there is no clear evidence of additional ASCVD event reduction from high-intensity therapy in this age group 1

Pediatric Dosing

• Ages 8 to <10 years with HeFH: 5-10 mg once daily 2
• Ages ≥10 years with HeFH: 5-20 mg once daily 2
• Ages ≥7 years with HoFH: 20 mg once daily 2

Critical Dose Modifications

Severe Renal Impairment (CrCl <30 mL/min/1.73 m²)

• Start at 5 mg once daily and do not exceed 10 mg daily in patients not on hemodialysis 3, 1, 2
• No dose adjustment needed for mild to moderate renal impairment 3

Asian Patients

• Initiate at 5 mg once daily due to significantly higher rosuvastatin plasma concentrations compared to white patients 1, 2
• Consider risks and benefits when treating Asian patients not adequately controlled at doses up to 20 mg once daily 2

Drug Interaction Dose Limits

• Cyclosporine, tacrolimus, everolimus, or sirolimus: Do not exceed 5 mg daily (7-fold increase in rosuvastatin exposure with severe muscle toxicity risk) 1, 2
• Teriflunomide, enasidenib, capmatinib: Do not exceed 10 mg daily 2
• Gemfibrozil: Avoid concomitant use; if necessary, initiate at 5 mg and do not exceed 10 mg daily 2
• Fostamatinib, febuxostat: Do not exceed 20 mg daily 2
• Resmetirom (for MASH/NASH): Limit rosuvastatin to 20 mg daily 1
• Protease inhibitors (atazanavir/ritonavir, lopinavir/ritonavir): Initiate at 5 mg and do not exceed 10 mg daily 2
• Darolutamide: Do not exceed 5 mg daily 2

Administration and Monitoring

Practical Administration

• Administer once daily at any time of day, with or without food 2
• Swallow tablets whole 2
• When taking with aluminum/magnesium hydroxide antacids, administer rosuvastatin at least 2 hours before the antacid 2

Monitoring Timeline

• Assess LDL-C as early as 4 weeks after initiating therapy and adjust dosage if necessary 2
• For statin conversions, monitor lipid levels 4-12 weeks after conversion to ensure equivalent efficacy 4

Comparative Efficacy Data

LDL-C Reduction by Dose

• Rosuvastatin 5 mg: 42-45% LDL-C reduction 5, 6
• Rosuvastatin 10 mg: 52% LDL-C reduction 5
• Rosuvastatin 20 mg: Approximately 55-60% LDL-C reduction 5
• Rosuvastatin 40 mg: 63% LDL-C reduction 5

Superior to Other Statins

• Rosuvastatin 10 mg produces significantly greater LDL-C reduction than atorvastatin 10 mg, simvastatin 20 mg, or pravastatin 40 mg 1, 5
• Rosuvastatin 5 mg is significantly more effective than atorvastatin 10 mg (42% vs 36% LDL-C reduction, P<0.001), simvastatin 20 mg (42% vs 36%, P<0.001), and pravastatin 20 mg (42% vs 27%, P<0.001) 6

Common Pitfalls 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 myopathy risk 1
• Do not exceed dose limits when prescribing with interacting medications, particularly cyclosporine (5 mg maximum) 1, 2
• Do not use simvastatin 80 mg as an alternative due to increased myopathy risk 7
• Verify the patient is not on hemodialysis before applying the severe renal impairment dosing restrictions 2

Safety Profile

• Myopathy incidence <0.1% at recommended doses of 5-40 mg daily 1
• Slight increased risk of new-onset diabetes, particularly in patients with metabolic syndrome features 1
• Safety profile comparable to other statins with acceptable tolerability across the dose range 5, 8, 9