Should pravastatin be used instead of Crestor (rosuvastatin) in patients who are symptomatic?

From the Guidelines

Switching from Crestor to pravastatin may be a viable option for patients experiencing side effects, as pravastatin is generally considered to be better tolerated and less likely to cause muscle pain and other symptoms. When considering this switch, it's essential to note that the decision should be based on the individual patient's needs and medical history. The PROVE-IT TIMI 22 study 1 demonstrated that intensive lipid lowering with atorvastatin resulted in a 16% reduction in the hazard ratio for the primary composite endpoint of all-cause death, MI, UA requiring rehospitalization, revascularization, and stroke, compared to standard-dose pravastatin. However, this study also highlighted the importance of careful monitoring and follow-up with aggressive treatment due to the increased incidence of myopathy in the high-dose atorvastatin group.

Some key points to consider when switching from Crestor to pravastatin include:

• The typical starting dose for pravastatin is 10-20 mg once daily, taken at bedtime, which can be adjusted up to 80 mg if needed based on cholesterol response 1.
• Pravastatin is less potent than Crestor, so a higher dose may be required to achieve similar cholesterol-lowering effects.
• There is no need for a washout period when switching from Crestor to pravastatin; the patient can start taking pravastatin the day after their last Crestor dose.
• Pravastatin tends to cause fewer side effects due to its lower fat solubility and reduced penetration into muscle tissue, as well as its different liver processing, which leads to fewer drug interactions 1.
• It is crucial to inform the doctor about the switch and report any persistent symptoms, as they may want to monitor liver enzymes and cholesterol levels after changing medications.

The 2019 systematic review for the AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1 provides further support for the use of statins, including pravastatin, in the management of patients with high cardiovascular risk. However, the decision to switch from Crestor to pravastatin should be made on a case-by-case basis, taking into account the individual patient's needs and medical history.

From the Research

Statin Alternatives

• There is no direct evidence to suggest trying pravastatin instead of crestor if symptomatic, as the provided studies focus on rosuvastatin and ezetimibe combinations.
• However, the studies do show that combination therapies, such as rosuvastatin and ezetimibe, can be effective in lowering LDL cholesterol levels and achieving lipid goals in patients with hypercholesterolemia or dyslipidemia 2, 3, 4, 5.
• One study compared ezetimibe/simvastatin to rosuvastatin, finding that the combination therapy provided greater reductions in LDL cholesterol and higher target attainment in patients on prior statin treatment, regardless of potency 6.

Combination Therapies

• The combination of rosuvastatin and ezetimibe has been shown to be safe and effective in patients with hypercholesterolemia or dyslipidemia, enabling higher proportions of patients to achieve recommended LDL-C goals than rosuvastatin monotherapy or other combination therapies 2, 3, 4, 5.
• Fixed-dose combinations of ezetimibe and rosuvastatin have been found to provide significantly superior efficacy to rosuvastatin alone in lowering LDL cholesterol, total cholesterol, and triglyceride levels 3, 5.

Patient Considerations

• Patients with diabetes mellitus or metabolic syndrome may experience greater benefits from combination therapies, such as ezetimibe plus rosuvastatin, compared to rosuvastatin alone 5.
• The effect of combination treatment on cholesterol levels may be more pronounced in patients with high-risk hypercholesterolemia, regardless of prior statin treatment potency 6.