Pravastatin Dose Equivalent to Rosuvastatin 5 mg
Pravastatin 40 mg daily provides LDL-cholesterol lowering approximately equivalent to rosuvastatin 5 mg in adults without severe hepatic impairment.
Evidence-Based Dose Equivalence
Direct Comparative Data
Rosuvastatin 5 mg achieves approximately 39–42% LDL-C reduction from baseline, placing it in the moderate-intensity statin category (30–49% reduction). 1, 2, 3
Pravastatin 40 mg produces approximately 34% LDL-C reduction, which is the closest equivalent among pravastatin doses to rosuvastatin 5 mg. 4
Head-to-head trials demonstrate that rosuvastatin 5 mg reduces LDL-C by 42% versus pravastatin 20 mg at 26.5%, confirming rosuvastatin's superior potency on a milligram-per-milligram basis. 2
Statin Intensity Classification Framework
The ACC/AHA guidelines classify rosuvastatin 5–10 mg as moderate-intensity therapy (30–49% LDL-C reduction), equivalent to atorvastatin 10–20 mg. 1
Pravastatin 40 mg is the standard dose that achieves moderate-intensity LDL-C lowering in the 30–40% range. 4, 5
Historical data from the PROVE IT trial established that pravastatin 40 mg produces LDL-C reduction equivalent to approximately 10 mg of atorvastatin, which itself is less potent than rosuvastatin 5 mg. 6
Practical Conversion Algorithm
Step 1: Assess Baseline LDL-C and Target
If the patient is currently on rosuvastatin 5 mg and achieving moderate-intensity LDL-C reduction (30–49%), switch to pravastatin 40 mg once daily. 1, 4
For patients requiring ≥40% LDL-C reduction, pravastatin 40 mg is the appropriate starting dose; pravastatin 20 mg achieves only 20–30% reduction and would be insufficient. 4, 7
Step 2: Initiate Pravastatin and Monitor
Start pravastatin 40 mg once daily at bedtime (pravastatin has a short half-life of ~2 hours, making evening dosing optimal for HMG-CoA reductase inhibition during peak cholesterol synthesis). 5
Recheck fasting lipid panel at 4–12 weeks to verify that LDL-C reduction remains in the 30–40% range. 1
Step 3: Dose Adjustment if Needed
If LDL-C reduction is inadequate (<30%), consider uptitrating to pravastatin 80 mg, which provides an additional ~6% LDL-C reduction per dose doubling. 4
Alternatively, if the patient requires >40% LDL-C reduction, switching back to a more potent statin (rosuvastatin 10 mg or atorvastatin 20 mg) may be necessary rather than maximizing pravastatin. 1, 7
Important Clinical Caveats
Rosuvastatin's Superior Potency
Rosuvastatin demonstrates approximately 1.5–2 times greater LDL-C lowering than pravastatin at comparable doses; rosuvastatin 5 mg is significantly more effective than pravastatin 20 mg (42% vs. 26.5% reduction). 2, 3
Even at the maximum pravastatin dose of 80 mg, LDL-C reduction may not fully match rosuvastatin 5 mg in all patients due to individual variability in statin response. 1
When Pravastatin May Be Preferred
Drug interaction considerations: Pravastatin is not metabolized via CYP3A4, making it safer than atorvastatin or simvastatin in patients on CYP3A4 inhibitors (e.g., certain protease inhibitors, amiodarone, clarithromycin). 1
Renal impairment: Unlike rosuvastatin, which requires dose limitation to 10 mg daily in severe renal impairment (CrCl <30 mL/min), pravastatin generally requires no renal dose adjustment. 1, 8
Common Pitfall to Avoid
Do not use pravastatin 20 mg as equivalent to rosuvastatin 5 mg—this dose achieves only 20–30% LDL-C reduction and would represent a significant therapeutic downgrade. 4, 2
Verify lipid response after conversion: Individual patient response to statins is highly variable; always confirm with follow-up lipid testing rather than assuming dose equivalence. 4