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.
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.
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.
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 the capsule must be opened, 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. It is essential for the mixture to be used promptly after preparation.
Dosage for the oral tablet is the same for the generic and trade name
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 on 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/min then no dosage adjustment is necessary; however, if lower than this cutoff the recommendation is to start the lowest possible dose of 5mg once daily with a maximum dosage of 10mg per day.
Clinically Relevant Adverse Effects
Rare adverse effects include diabetes mellitus, hematuria, proteinuria, and hypersensitivity.
Other reported symptomatic adverse effects include headache, dizziness, nausea, constipation, interstitial cystitis, arthralgia, and weakness.
The following monitoring parameters are from the American College of Cardiology and the American Heart Association Cholesterol Guideline Recommendations.
Creatinine phosphokinase (CPK) levels should not be routinely measured; however, special considerations for measuring CPK can be based 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 obtaining 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 dose should be decreased.
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.
Rosuvastatin is a widely used medication for serum lipid-lowering. The drug is known to be effective for elevated lipid levels and 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 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, it is imperative for the pharmacist to notify the provider immediately. 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.
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