Is rosuvastatin 40mg really better than atorvastatin 80mg?
I heard this from one of you this week, and it made me realize I needed to look it up! Crestor only became generically available during my last year of fellowship, so for the bulk of my training, I was preferentially prescribing atorvastatin. This is a good reminder for me and lesson for you about how strongly your prescribing patterns can develop during your training.
At any rate, I read two articles. The first, attached, was an RCT looking at these two drugs in patients with CAD in South Korea. The mean rosuvastatin dose was 17mg, and the mean atorvastatin dose was 36mg, which I think is a fair representation of the question I’m asking. The initial trial looked at targeting LDL v statin intensity; this is a secondary analysis of the two statin medications. They had pretty good follow up, and as you can see here, the rosuvastatin group had a borderline clinically though not statistically significantly higher curve for MACE, and slightly lower LDL levels.
The authors point out in the Discussion section that rosuvastatin has a better bonding interaction with HMG-CoA reductase and a slightly longer half-life than does atorvastatin, which may explain the findings. However, atorvastatin may have more pleiotropic effects due to its lipophilic properties.
The authors also looked at a number of secondary outcomes: new DM, ESRD, hospital admission, VTE, revasc/intervention for PAD/aorta, cataract surgery, and some labs. They found that patients in the rosuvastatin group were slightly more likely to develop DM and have cataract surgery. In the Discussion, they acknowledge it’s hard to know how much of the incident diabetes we see is a class versus a specific drug effect, and that this study protocol did not mandate any screening for cataracts. For me, both of these observations are hypothesis-generating, not conclusive.
One big limitation of this study is that clinicians were encouraged not to use ezetimibe, which limits our real world applicability. For what its worth, the authors found ezetimibe was used less in the rosuvastatin group than in the atorvastatin group, which perhaps also says something about efficacy, but may also just confound the results.
I also skimmed through this real world study of rosuvastatin and atorvastatin use in Spain and pulled a few takeaways:
Of the ~10% of patients who changed their lipid drugs due to adverse effects, half went from atorvastatin to rosuvastatin
There was not a significant difference between rosuvastatin and atorvastatin in terms of achieving LDL goals:
Figure 2. LDL-C goal attainment by lipid-lowering therapy (n = 1482).
We still have a lot of work to do to get to our LDL goals
Statins improve LDL levels by ~50% in trials but in real world that number may be closer to ~35%, especially for higher risk patients
I know this is an area some of you know much better than me, would appreciate your thoughts if so! Otherwise, my takeaway is that either statin is probably okay, and that we should be sure to follow up on our LDL targets.
Barrios V, Pintó X, Escobar C, Varona JF, Gámez JM. Real-World Attainment of Low-Density Lipoprotein Cholesterol Goals in Patients at High Risk of Cardiovascular Disease Treated with High-Intensity Statins: The TERESA Study. Journal of Clinical Medicine2023;12(9):3187-3187. doi:10.3390/jcm12093187
Lee YJ, Hong SJ, Kang WC, et al. Rosuvastatin versus atorvastatin treatment in adults with coronary artery disease: secondary analysis of the randomised LODESTAR trial. BMJ2023;383(383):e075837. doi:10.1136/bmj-2023-075837
