What Rosuvastatin does
Rosuvastatin is a high-intensity statin, at 20 to 40 mg doses it can lower LDL by 50 percent or more. It has a long half-life, can be dosed any time of day, and is one of only two statins recommended for use in patients of Asian ancestry at half-dose because of pharmacokinetic differences.
What the evidence says for Black patients
The JUPITER trial (Ridker et al., NEJM 2008;359:2195 to 2207, PMID 18997196) randomized 17,802 adults with low LDL but elevated CRP and showed a 44 percent relative risk reduction in major CV events. The Black subgroup (approximately 12.5 percent of participants, unusually strong Black representation for a CV trial) showed a 37 percent risk reduction, consistent with the overall trial and confirming statin benefit in primary prevention for Black adults at elevated inflammatory risk.
Rosuvastatin has less CYP3A4 metabolism than atorvastatin or simvastatin, making it a good choice for patients on HIV protease inhibitors, anti-rejection drugs, or other CYP3A4 substrates, all over-represented among clinical populations that include higher proportions of Black patients (HIV, transplant).
The FDA label notes a recommended 5 mg starting dose for Asian patients due to roughly 2-fold higher plasma levels; there is no analogous label-level adjustment for Black patients, and PK data do not show meaningful Black-vs-white differences.
How your genes can change this drug
Some people process rosuvastatin differently because of an inherited gene variant, and the difference is large enough that prescribing guidelines address it. The recommendations below are published by CPIC, the Clinical Pharmacogenetics Implementation Consortium, and are quoted as written. They are guidance for prescribers, not instructions to change your own dose.
Prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. Prescriber should be aware of possible increased risk for myopathy especially for doses >20mg. Prescribe ≤10mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >10mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). Prescribe ≤10mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >10mg needed for desired efficacy, consider combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). Prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose > 20mg needed for desired efficacy, consider combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). Prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). Prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >20mg needed for desired efficacy, consider combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). Prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. Based on SLCO1B1 status, prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. Prescriber should be aware of possible increased risk for myopathy especially for doses >20mg. ABCG2 genotype result is not available. Based on SLCO1B1 status, prescribe desired starting dose and adjust doses based on disease-specific guidelines. ABCG2 genotype result is not available. Based on ABCG2 status, prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific guidelines and specific population guidelines. SLCO1B1 phenotype could not be assigned based on genotyping. n/a Based on ABCG2 status, prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. SLCO1B1 phenotype could not be assigned based on genotyping. Based on ABCG2 status, prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). SLCO1B1 phenotype could not be assigned based on genotyping. Based on ABCG2 status, prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific guidelines and specific population guidelines. SLCO1B1 genotype result is not available. Based on ABCG2 status, prescribe desired starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. SLCO1B1 genotype result is not available. Based on ABCG2 status, prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines. If dose >20mg needed for desired efficacy, consider an alternative statin or combination therapy (i.e., rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). SLCO1B1 genotype result is not available. Based on SLCO1B1 status, prescribe ≤20mg as a starting dose and adjust doses of rosuvastatin based on disease-specific and specific population guidelines If dose >20mg needed for desired efficacy, consider combination therapy (i.e. rosuvastatin plus non-statin guideline directed medical therapy) (PMID: 30423391). ABCG2 genotype result is not available.
Genetic testing for these variants is available but is not routine. If you have had a reaction to this drug, or it has not worked for you, this is worth raising with your prescriber. Do not stop or change a prescription on your own.
Common alternatives
Atorvastatin is the main alternative high-intensity statin. Pitavastatin has favorable DDI profile. Ezetimibe or a PCSK9 inhibitor can be added if LDL goals are not met.
Side effects
- Muscle aches
- Proteinuria (transient, dose-related)
- Small diabetes risk
- Transaminase elevation
Factors that affect adherence
Generic rosuvastatin is on the $4 list. Patients who had myalgia on atorvastatin often tolerate rosuvastatin, and vice versa, cross-tolerance is common but not universal.
Questions to ask your doctor
Bring this list to your next appointment.
- Is 20 mg or 40 mg right for my LDL goal?
- Am I on any drugs that interact?
- If I had muscle aches on another statin, should I try rosuvastatin?
References
- Ridker PM, Danielson E, Fonseca FA, et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein (JUPITER). NEJM. 2008;359:2195 to 2207. PMID 18997196.
- Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC Cholesterol Guideline. JACC. 2019;73:e285 to e350.
- U.S. Food and Drug Administration. Crestor (rosuvastatin calcium) label. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/021366s032lbl.pdf
Medical disclaimer
This page is patient education, not prescribing guidance. It summarizes the published evidence about how this medication has been studied in Black patients, it is not a substitute for the judgment of your personal clinician. Never start, stop, or change a prescription based on something you read here. If you have questions about your medication, call your prescriber or pharmacist. For emergencies, call 911.
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