Atorvastatin vs Rosuvastatin
Clinical Comparison
Clinical Context
NICE recommends atorvastatin 20 mg for primary prevention and 80 mg for secondary prevention. Rosuvastatin is reserved for patients who do not achieve adequate LDL reduction on atorvastatin, or who cannot tolerate it due to drug interactions. Rosuvastatin is the most potent statin available, offering greater LDL reduction at equivalent doses.
Drug Profiles
Atorvastatin
HMG-CoA reductase inhibitor (statin)
Mechanism
Competitively inhibits HMG-CoA reductase in the liver, reducing cholesterol synthesis and upregulating LDL receptors
Indications
- Primary prevention of cardiovascular disease
- Secondary prevention post-MI/stroke
- Familial hypercholesterolaemia
- Type 2 diabetes with CVD risk factors
Common Doses
Primary prevention: 20 mg OD; Secondary prevention: 80 mg OD
Route
Oral
Onset & Duration
LDL reduction within 2 weeks; maximum effect 4-6 weeks; half-life 14 hours
Rosuvastatin
HMG-CoA reductase inhibitor (statin)
Mechanism
Competitively inhibits HMG-CoA reductase with highest binding affinity of all statins, reducing cholesterol synthesis
Indications
- Hypercholesterolaemia (primary and familial)
- Secondary prevention of cardiovascular events
- When atorvastatin does not achieve LDL targets
Common Doses
5-10 mg OD initially; max 40 mg OD (20 mg max in Asian patients)
Route
Oral
Onset & Duration
LDL reduction within 1-2 weeks; maximum effect 4 weeks; half-life 19 hours
Key Differences
| Category | Atorvastatin | Rosuvastatin |
|---|---|---|
| LDL-lowering potency | 40-50% reduction at 20 mg; up to 55% at 80 mg | 45-55% at 10 mg; up to 63% at 40 mg — most potent statin |
| NICE position | First-line for primary and secondary prevention | Reserved for atorvastatin failure or intolerance |
| Drug interactions | Metabolised by CYP3A4 — grapefruit, macrolides, azoles | Minimal CYP metabolism — fewer interactions |
| Cost | Very cheap generic | Slightly more expensive (still affordable) |
| Asian patients | No specific dose cap | Max 20 mg in Asian patients (pharmacogenomic difference) |
| Renal excretion | Minimal renal excretion | ~28% renally excreted — caution in severe renal impairment |
LDL-lowering potency
40-50% reduction at 20 mg; up to 55% at 80 mg
45-55% at 10 mg; up to 63% at 40 mg — most potent statin
NICE position
First-line for primary and secondary prevention
Reserved for atorvastatin failure or intolerance
Drug interactions
Metabolised by CYP3A4 — grapefruit, macrolides, azoles
Minimal CYP metabolism — fewer interactions
Cost
Very cheap generic
Slightly more expensive (still affordable)
Asian patients
No specific dose cap
Max 20 mg in Asian patients (pharmacogenomic difference)
Renal excretion
Minimal renal excretion
~28% renally excreted — caution in severe renal impairment
Key Advantages
Atorvastatin
- NICE first-line statin for both primary and secondary prevention
- Can be taken at any time of day (long half-life)
- Extensive evidence base (CARDS, TNT, SPARCL trials)
- Very cheap as generic
Rosuvastatin
- Most potent statin — greatest LDL reduction per mg
- Minimal CYP450 metabolism — fewer drug interactions
- Can be taken at any time of day
- Effective when atorvastatin fails to achieve targets
Key Cautions
Atorvastatin
- Myalgia (5-10% of patients)
- Rhabdomyolysis (rare)
- Hepatotoxicity — check LFTs at baseline and 3 months
- CYP3A4 interactions (clarithromycin, grapefruit, ciclosporin)
- Avoid in pregnancy and breastfeeding
Rosuvastatin
- Higher myopathy risk at 40 mg dose
- Proteinuria at high doses
- Dose cap at 20 mg for Asian patients (higher bioavailability)
- Not first-line per NICE — used when atorvastatin is inadequate or not tolerated
- Slightly higher cost than atorvastatin
Clinical Verdict
Start with atorvastatin per NICE guidelines. Switch to rosuvastatin if LDL targets are not met at maximum tolerated atorvastatin, or if CYP3A4 drug interactions are a concern.
Medical Disclaimer: This comparison is for educational purposes only and is not a substitute for professional medical advice. Always consult a qualified healthcare professional before making prescribing decisions. Verify all drug information with current clinical guidelines (BNF, NICE, SmPCs).
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