Rosuvastatin


Article Author:
Tushar Bajaj


Article Editor:
Al Giwa


Editors In Chief:
James Beauchamp
Mark Pellegrini
Nicole Hale-Crutch


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Abdul Waheed
Khalid Alsayouri
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Altif Muneeb
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Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
10/6/2019 4:22:37 PM

Indications

Rosuvastatin is a statin medication used as a lipid-lowering agent. The FDA-approved indications are homozygous familial hypercholesterolemia, hyperlipidemia, mixed dyslipidemia, primary dysbetalipoproteinemia, hypertriglyceridemia, and prevention of cardiovascular disease. The non-FDA approved uses are in non-cardioembolic stroke, secondary prevention in transient ischemic attack (TIA), and as perioperative therapy for cardiac risk reduction in noncardiac surgeries.

Mechanism of Action

The mechanism of action of rosuvastatin is inhibition of 3-hydroxy-3-methyl-glutaryl coenzyme A (HMG-CoA) reductase. This enzyme is the rate-limiting step in cholesterol synthesis, which reduces the production of mevalonic acid from HMG-CoA. Furthermore, this results in an increase of low-density lipoprotein receptors on hepatocyte membranes and stimulation of low-density lipoprotein catabolism. HMG-CoA reductase inhibitors also decrease levels of high sensitivity C-reactive protein (CRP). They also possess pleiotropic properties, including inhibition of platelet aggregation, anticoagulant effects, reduced inflammation at the site of a coronary plaque, and improved endothelial function.[1][2]

Rosuvastatin is not extensively metabolized, with approximately 10% of a radiolabeled dose being recoverable as a metabolite.  The pharmacokinetic properties of statin medications vary, however, rosuvastatin is unique in that its half-life is 19 hours, bioavailability is 20%, protein binding is 88%, possesses hydrophilic solubility, metabolized by CYP2C9, and primarily fecally excreted (90%) with only 10% urinary excretion.[3]

Administration

The administration of rosuvastatin is via capsule or tablet. The capsule can be administered orally or via a nasogastric tube. The oral route can be taken with or without food, at any time of the day, and should be swallowed whole. The capsule should never be crushed or chewed. If opening the capsule, it is recommended to empty the contents into one teaspoonful of applesauce and then swallowed immediately without chewing.

For administration with a nasogastric tube, the capsule can be opened, emptied into a 60ml catheter-tipped syringe. The recommendation is to add 40 milliliters of water, replace the plunge, shake syringe for 15 seconds. Then attach the syringe to at least a 16 French nasogastric tube and administer with an additional flush of the tube with 20 milliliters of water. The mixture needs to be used promptly after preparation.

Dosage for the oral tablet is the same for the generic and trade name

  • 5 mg, 10 mg, 20 mg, 40 mg

Dosage recommendations: Dosing is individualized based on the low-density lipoprotein (LDL) levels at baseline and the goal of therapy. The patient’s response and adherence to medication is an important determinant to therapeutic success. Adjustments should be made at a regular interval of four weeks or more depending on the underlying pathology of the disease and whether the treatment is for primary versus secondary prevention. Due to the risk of significant drug-drug interactions, the adjustment in dosing should be part of medication reconciliation with the current literature and a pharmacist. In renal impairment, if the creatinine clearance is greater or equal to 30 ml/minute, then no dosage adjustment is necessary; however, if lower than this cutoff, the recommendation is to start the lowest possible dose of 5 mg once daily with a maximum dosage of 10 mg per day.

Adverse Effects

Clinically Relevant Adverse Effects[4]

  • Creatinine kinase of greater than ten times the upper limit of normal
  • Severe myopathy
  • Rhabdomyolysis
  • AST or ALT elevations of greater than three times the upper limit of normal
  • Renal failure

Rare adverse effects include diabetes mellitus, hematuria, proteinuria, and hypersensitivity.

Other reported symptomatic adverse effects to include headache, dizziness, nausea, constipation, interstitial cystitis, arthralgia, and weakness.

Drug-Drug Interactions:

  1. The following medications may enhance the myopathic effect of Rosuvastatin: acipimox, bezafibrate, ciprofibrate, colchicine, daptomycin, fenofibrate, fusidic acid, gemfibrozil, niacin, niacinamide, raltegravir, red yeast rice, rupatadine
  2. The following medications may decrease the serum concentration of rosuvastatin: antacids, apalutamide, elagolix, eslicarbazepine
  3. The following medications may increase the serum concentrations of rosuvastatin: asunaprevir, clopidogrel, cobicistat, cyclosporine, daclatasvir, dasabuvir, dronedarone, elbasvir, eltrombopag, eluxadoline, fostamatinib, glecaprevir, pibrentasvir, grazoprevir, itraconazole, ledipasvir, letermovir, ombitasvir, paritaprevir, ritonavir, osimertinib, protease inhibitors, simeprevir, teriflunomide, velpatasvir, voxilaprevir

Contraindications

As with many drugs, if the patient has a hypersensitivity to rosuvastatin or any component of the drug formulation, they must discontinue the drug. Other contraindications are listed below[5][6]

  • Pregnancy (pregnancy category X)
    • There are reports of congenital anomalies
  • Breastfeeding
  • Active liver disease
  • Unexplained persistent elevations of serum transaminases

Monitoring

The following monitoring parameters are from the American College of Cardiology and the American Heart Association Cholesterol Guideline Recommendations.[7]

Creatinine phosphokinase (CPK) levels should not be routinely measured; however, the clinician can base special considerations for measuring CPK on family history of statin intolerance, drug-drug interactions leading to increased risk of myopathy, or other clinical presentations that create a high index of suspicion of myopathy.

Aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, and total bilirubin levels do not need to measured routinely. Only if symptoms suggest underlying hepatotoxicity during therapy, it may be beneficial to obtain these levels.

Lipid panel testing, including low-density lipoprotein, high-density lipoprotein, triglycerides, and total cholesterol should be obtained on an initial visit to establish a baseline. Thereafter, a fasting lipid profile within four to twelve weeks after initiation or dose adjustment should be obtained. Furthermore, after receiving these initial two levels, further fasting lipid profiles are only necessary every three to twelve months, or as clinically indicated. If two consecutive low-density lipoprotein levels are less than 40 milligrams per deciliter, the clinician should decrease the dose.

Toxicity

The most common toxic side effect of rosuvastatin is myalgia. If the patient has mild to moderate muscle symptoms, the drug should be discontinued to evaluate for other causes of myalgia. If there is a resolution of the underlying etiology, the patient can restart the original or a lower dose of rosuvastatin; however, if symptoms reoccur for a second time, then discontinue rosuvastatin indefinitely. Switching to a different statin medication at a lower dose may relieve muscle symptoms.

It is clear that if severe muscle symptoms or fatigue occur, the provider should discontinue the medication, and order a creatinine phosphokinase level, serum creatinine, and a urinalysis to evaluate for myoglobinuria.

Enhancing Healthcare Team Outcomes

Rosuvastatin is a widely used medication for serum lipid-lowering. The drug is known to be effective for elevated lipid levels and the prevention of cardiovascular disease. Prescribing and monitoring the patient will require communication via the provider, pharmacist, and other subspecialties such as cardiologists who may have a role in adjusting the dosage of the medication. Monitoring for the effect of the drug and dose adjustment is best accomplished via a multidisciplinary approach, although it is manageable by a single provider. The drug does have multiple drug-drug interactions; therefore, it is helpful for pharmacists to check and flag any interactions. If any drug-drug interactions are present, the pharmacist must notify the provider immediately. Nursing also bears responsibility for monitoring for adverse reactions, helping assess therapeutic effectiveness, and offering counsel to the patient, as well as serving as a bridge between the pharmacist and other providers and the prescriber. The prescribing provider should determine the risks versus benefits of the medication in conjunction with the patient after an informed consent discussion with shared decision making. Only with a collaborative interprofessional team approach can rosuvastatin therapy be optimized to deliver the appropriate therapeutic results for the patient. [Level V]


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Rosuvastatin - Questions

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Which of the following medications can maximally increase high-density lipoprotein levels?



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In which medication class does rosuvastatin belong?



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Which of the following is used to treat elevated serum lipid levels?



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Which one of the following is the generic drug name for branded Crestor?



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A 65-year-old patient has been on rosuvastatin 20 mg for the past two months for hyperlipidemia. He starts to complain of muscle pain in his hamstrings as well as easy fatigue. His provider discontinues the medication. After three months, the symptoms resolve. The patient is put back on rosuvastatin at 10 mg. However, one month later, the myalgia symptoms reoccur. What is the best next step in management?



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A 45-year-old obese male with a history of coronary artery disease, hypertension, diabetes mellitus type 2, hyperlipidemia, and gout presents to the outpatient clinic for increasing muscle pain in his arms and legs for the past 2 months. His vitals are stable, and his medications include aspirin, lisinopril, metformin, rosuvastatin, and colchicine. The patient has had no modifications to his medications and is asymptomatic otherwise. Which of the following agents in his regimen could increase the myopathic effect of rosuvastatin?



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A 36-year-old Female G1P1 presents to the clinic for a prenatal visit. She plans on becoming pregnant as soon as possible with her husband. The patient's only medication is rosuvastatin for hypertriglyceridemia. Which of the following recommendations should be made?



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Rosuvastatin - References

References

De Denus S,Spinler SA, Early statin therapy for acute coronary syndromes. The Annals of pharmacotherapy. 2002 Nov;     [PubMed]
Ray KK,Cannon CP, The potential relevance of the multiple lipid-independent (pleiotropic) effects of statins in the management of acute coronary syndromes. Journal of the American College of Cardiology. 2005 Oct 18;     [PubMed]
Kostapanos MS,Milionis HJ,Elisaf MS, Rosuvastatin-associated adverse effects and drug-drug interactions in the clinical setting of dyslipidemia. American journal of cardiovascular drugs : drugs, devices, and other interventions. 2010;     [PubMed]
Grundy SM,Stone NJ,Bailey AL,Beam C,Birtcher KK,Blumenthal RS,Braun LT,de Ferranti S,Faiella-Tommasino J,Forman DE,Goldberg R,Heidenreich PA,Hlatky MA,Jones DW,Lloyd-Jones D,Lopez-Pajares N,Ndumele CE,Orringer CE,Peralta CA,Saseen JJ,Smith SC Jr,Sperling L,Virani SS,Yeboah J, 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. Circulation. 2018 Nov 10;     [PubMed]
Godfrey LM,Erramouspe J,Cleveland KW, Teratogenic risk of statins in pregnancy. The Annals of pharmacotherapy. 2012 Oct;     [PubMed]
Lecarpentier E,Morel O,Fournier T,Elefant E,Chavatte-Palmer P,Tsatsaris V, Statins and pregnancy: between supposed risks and theoretical benefits. Drugs. 2012 Apr 16;     [PubMed]
Schachter M, Chemical, pharmacokinetic and pharmacodynamic properties of statins: an update. Fundamental     [PubMed]

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