How to Discontinue Rosuvastatin
Do not abruptly stop rosuvastatin without a compelling medical indication, as discontinuation—particularly in patients with established cardiovascular disease—significantly increases cardiovascular morbidity and mortality. 1
Immediate Discontinuation Required
Discontinue rosuvastatin immediately in the following situations:
- Severe muscle symptoms: Unexplained severe muscle pain, tenderness, weakness, or fatigue with concern for rhabdomyolysis 2, 1, 3
- Markedly elevated CK: CK >10 times upper limit of normal with muscle symptoms 2, 1, 3
- Suspected rhabdomyolysis: Evaluate CK, creatinine, and urinalysis for myoglobinuria 2, 3
- Serious hepatic injury: Clinical symptoms with hyperbilirubinemia or jaundice 3
Temporary Discontinuation Protocol
For mild to moderate muscle symptoms, follow this structured approach:
Step 1: Discontinue and Evaluate (Weeks 0-2)
- Temporarily stop rosuvastatin until symptoms can be evaluated 2, 1, 4
- Measure CK levels to establish causality and assess for muscle damage 2, 5, 1
- Screen for secondary causes that increase muscle symptom risk 2, 5, 1:
- Hypothyroidism (TSH)
- Vitamin D deficiency
- Reduced renal or hepatic function
- Rheumatologic disorders (polymyalgia rheumatica)
- Drug interactions (CYP3A4 inhibitors, gemfibrozil, cyclosporine)
Step 2: Wait for Resolution (2 Weeks to 2 Months)
- Allow complete symptom resolution and CK normalization before any rechallenge 5, 1
- Most symptoms resolve within 2 weeks to 2 months 5, 1
Step 3: Rechallenge Strategy (After Resolution)
Option A: Resume rosuvastatin at lower dose
- Restart at 5 mg daily or 5 mg every other day to establish causality 2, 5, 4
- If symptoms recur, this confirms rosuvastatin-induced myopathy 5
Option B: Switch to alternative statin with lower myopathy risk
- First-line alternatives: Pitavastatin (preferred) or fluvastatin 5
- Second-line: Pravastatin 5
- These statins have different metabolic pathways and lower muscle-related adverse event rates 5
Option C: Alternate-day dosing with rosuvastatin
- Use rosuvastatin 5-20 mg every other day or Monday/Wednesday/Friday dosing 5, 6, 7, 8
- The 19-hour half-life of rosuvastatin makes alternate-day dosing viable 6, 8
- Studies show 72.5% tolerability with 34.5% LDL-C reduction using this approach 7
Step 4: Add Non-Statin Therapy if Needed
If symptoms recur with any statin rechallenge:
- Add ezetimibe 10 mg as monotherapy or with maximally tolerated statin dose 2, 5
- Consider PCSK9 inhibitors (evolocumab, alirocumab) or inclisiran if LDL goal cannot be achieved 2, 5
- Bempedoic acid is another option for statin-intolerant patients 2
Special Populations Requiring Discontinuation Consideration
Elderly patients (≥75 years) 2, 1:
- Continue rosuvastatin in those with established cardiovascular disease and good functional status 1
- Consider discontinuation in those with:
Critical Monitoring After Any Change
- Monitor muscle symptoms at 6-12 weeks after starting new therapy and at each follow-up visit 5, 1
- Measure CK levels whenever patient reports muscle soreness, tenderness, or weakness 5, 1
- Assess LDL-C as early as 4 weeks after any dosage change 3
Common Pitfalls to Avoid
- Do not permanently discontinue without establishing causality through rechallenge—90% of adverse symptoms may be nocebo effects 5
- Do not assume true statin intolerance until the patient has failed at least 2-3 different statins 5
- Do not combine rosuvastatin with gemfibrozil, high-dose niacin (>1 gram/day), or cyclosporine, which substantially increase myopathy risk 5, 3
- Do not stop abruptly in patients with recent acute coronary syndrome or established cardiovascular disease without a compelling reason 2, 1
- Obtain baseline muscle symptom history before initiating any statin to avoid unnecessary discontinuation 2, 1