Rosuvastatin vs Atorvastatin: Which To Take?

Milligram for milligram, rosuvastatin is stronger. In the STELLAR trial of about 2,400 adults with high LDL, rosuvastatin 10 mg lowered LDL by about 46% and atorvastatin 10 mg by about 37%. Across the whole dose range, rosuvastatin lowered LDL by an average of 8.2 percentage points more.

Both reach high intensity (an LDL drop of 50% or more): rosuvastatin at 20 to 40 mg, atorvastatin at 40 to 80 mg. Each step up in dose adds a smaller extra drop, so recheck your LDL after starting to see how well yours works.

At doses that lower LDL by a similar amount, the two perform about the same. LODESTAR, a randomized trial of 4,400 Korean adults with coronary artery disease, followed people for three years. Death, heart attack, stroke, or a procedure to reopen an artery happened in 8.7% on rosuvastatin and 8.2% on atorvastatin, a gap that could easily be chance.

LODESTAR was open label (everyone knew which drug they got), and it enrolled only Korean adults. Its secondary findings need confirming.

Overall they look similar. Muscle risk rises with dose and blood levels for both, and most muscle aches blamed on either drug also show up on placebo in blinded trials.

In LODESTAR, new diabetes needing medication was 7.2% on rosuvastatin versus 5.3% on atorvastatin, and cataract surgery was 2.5% versus 1.5%. The doses weren't matched for LDL effect. All statins raise blood sugar slightly, mostly in people already close to diabetes.

Atorvastatin needs no dose change for kidney disease. Rosuvastatin is partly cleared by the kidneys, so with severe kidney impairment (creatinine clearance below 30 mL/min) its label says to start at 5 mg and stay at or below 10 mg.

Atorvastatin is broken down by the liver enzyme CYP3A4, so medicines that block that enzyme can raise its levels. Its label advises against more than 1.2 liters of grapefruit juice a day. Rosuvastatin isn't meaningfully affected by CYP3A4 or grapefruit, though it has interactions of its own. Bring a full medicine list, including supplements, to whoever prescribes.

Yes, mostly for rosuvastatin. The FDA label reports about twice the blood levels in people of Asian ancestry and recommends starting at 5 mg. A reduced-function ABCG2 gene variant, more common in East Asian populations, explains part of that.

A variant in SLCO1B1 raises blood levels of both drugs. Guidelines advise lower starting doses for carriers. Optional genetic testing can check for it.

People switch between these two often, usually for more LDL lowering at a lower milligram dose, to avoid a drug interaction, or after side effects. The milligrams aren't equivalent, so the dose needs converting, and your LDL should be rechecked a few weeks to a few months later. Ask your clinician before changing anything.