Can a patient with coronary artery disease and elevated liver function tests on atorvastatin be started on rosuvastatin (Crestor) instead?

Can a Patient with CAD and Elevated LFTs on Atorvastatin Switch to Rosuvastatin?

Yes, a patient with coronary artery disease and elevated liver function tests on atorvastatin can be switched to rosuvastatin, and in fact, continuing statin therapy—whether atorvastatin or rosuvastatin—is both safe and beneficial even with mild-to-moderate LFT elevations. 1, 2

Key Decision Points

Continue Statin Therapy Despite Elevated LFTs

• Mild-to-moderate LFT elevations (<3x upper limit of normal) are not a contraindication to statin therapy and should not prompt discontinuation. 1, 2
• Patients with CAD and mildly elevated baseline ALT who received intensive statin therapy (atorvastatin 80 mg) had a 44% reduction in major cardiovascular events compared to those with normal ALT, demonstrating greater benefit in this population. 1
• In the GREACE study, patients with moderately abnormal liver tests treated with statins (primarily atorvastatin 24 mg daily) experienced 68% relative risk reduction in cardiovascular events versus untreated patients (10% vs 30% event rate, p<0.0001). 2
• Statin therapy actually improved liver enzyme levels over time in patients with baseline elevations, likely by treating underlying non-alcoholic fatty liver disease. 2

Switching to Rosuvastatin: Evidence and Rationale

Rosuvastatin is a reasonable alternative to atorvastatin and may offer advantages in patients with elevated LFTs:

• Rosuvastatin produces the same rate of hepatic enzyme elevations as other statins, with no evidence of causing significant liver injury. 3
• Long-term rosuvastatin administration does not decline renal function and actually produces modest improvement in glomerular filtration rate. 3
• Rosuvastatin has less drug-drug interaction potential with certain medications (e.g., sacubitril/valsartan) compared to atorvastatin, potentially reducing adverse effects. 4
• Both rosuvastatin 20 mg and atorvastatin 40 mg are considered high-intensity statins for secondary prevention in CAD patients. 5, 6

Practical Switching Strategy

If switching from atorvastatin to rosuvastatin:

• Start rosuvastatin 20 mg daily (equivalent high-intensity therapy to atorvastatin 40-80 mg). 5, 6
• Monitor LFTs at baseline and 4-6 weeks after the switch. 5
• Target LDL-C <55 mg/dL (<1.4 mmol/L) for post-ACS or very high-risk CAD patients. 5
• If LDL-C target not achieved after 4-6 weeks, add ezetimibe rather than increasing statin dose. 5

When to Actually Stop Statins

Only discontinue statin therapy if:

• Transaminase levels exceed 3x the upper limit of normal. 2
• Patient develops symptoms of hepatotoxicity (jaundice, severe fatigue, dark urine). 7
• Less than 1% of patients require discontinuation for liver-related adverse effects. 2

Important Caveats

• Borderline LFT elevations (<2x ULN) are common with both atorvastatin and rosuvastatin and persist over time without clinical significance. 8
• Greater LFT elevations are more common with atorvastatin 40 mg than rosuvastatin 20 mg, though both remain clinically insignificant. 8
• Atorvastatin 80 mg increases risk of elevated liver enzymes 6-fold (0.2% to 1.2%) compared to lower doses, but without increased liver failure. 9
• The cardiovascular benefit of continuing statin therapy far outweighs the theoretical hepatic risk in patients with mild-to-moderate LFT elevations. 1, 2

Bottom Line Algorithm

1. Verify LFT elevation is <3x ULN → Continue statin therapy 2
2. If patient preference or concern about atorvastatin → Switch to rosuvastatin 20 mg daily 5, 3
3. If staying on atorvastatin → Consider dose reduction to 40 mg if on 80 mg, or continue current dose 8, 1
4. Recheck LFTs in 4-6 weeks → Expect improvement or stabilization 2
5. Add ezetimibe if LDL-C >55 mg/dL after 4-6 weeks on optimized statin 5
6. Only discontinue if LFTs >3x ULN or symptoms of hepatotoxicity develop 2