Published: 3 September 2026

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Rosuvastatin: Dose considerations

Published: 3 September 2026
Prescriber Update 47(3): 41–43
September 2026

Key messages

  • The usual starting dose of rosuvastatin for hypercholesterolemia is 5-10 mg regardless of prior history of statin use. If necessary, the dose can be increased after 4 weeks of treatment. The usual maximum dose is 20 mg per day.
  • As with all statins, rosuvastatin can cause skeletal muscle toxicity, and the risk of rhabdomyolysis increases with higher rosuvastatin doses. Be aware of other risk factors for skeletal muscle toxicity with rosuvastatin and recommended dose modifications.
  • Advise patients to promptly report unexplained muscle pain, tenderness or weakness, particularly if accompanied by malaise or fever.
  • Only use the 40 mg dose in patients who have not responded to the 20 mg dose, ie, who still have severe hypercholesterolaemia and are at high cardiovascular risk. The 40 mg dose is contraindicated in some patients.


The New Zealand Pharmacovigilance Database recently received a report concerning a person of Asian ethnicity who was switched from another statin to rosuvastatin 40 mg per day and subsequently experienced acute kidney injury, muscle pain, increased creatinine phosphokinase (over 10,000 units/L) and hyperkalaemia. This case highlights the importance of using the correct rosuvastatin dose (taking into account individual patient risk factors).

Rosuvastatin indications and potency

Rosuvastatin is a statin indicated in the management of hypercholesteremia and the prevention of major cardiovascular events. Statins inhibit a key enzyme in the synthesis of cholesterol, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase.1

Rosuvastatin is the most potent of the statins available in New Zealand, meaning that it achieves its therapeutic effect at lower doses than pravastatin, simvastatin and atorvastatin.2

Due to its potency, the recommended rosuvastatin starting dose for treatment of hypercholesterolaemia is 5 mg or 10 mg once per day both in statin naïve patients and in those switched from another HMG-CoA reductase inhibitor. A dose adjustment can be made after 4 weeks of treatment as necessary. The usual maximum dose is 20 mg per day. For prevention of cardiovascular events, the dose is 20 mg per day.1

As with other statins, rosuvastatin is associated with skeletal muscle toxicity (myopathy and rhabdomyolysis), and the reported rate for rhabdomyolysis is higher at the highest rosuvastatin dose.1 Advise patients to promptly report unexplained muscle pain, tenderness or weakness, particularly if accompanied by malaise or fever.1

Regardless of the indication, use rosuvastatin with caution in patients with additional risk factors for skeletal muscle toxicity, as described below.

Start rosuvastatin at a low dose in patients with risk factors1

Certain patients are more at risk of skeletal muscle toxicity because of increased systemic exposure to rosuvastatin. This includes patients of Asian origin, with severe renal or hepatic impairment, advanced age, concomitant use of medicines that increase rosuvastatin levels and patients with certain genetic polymorphisms, as shown in Table 1. Dose modifications are needed for these patients.

Table 1: Risk factors for skeletal muscle toxicity and recommended rosuvastatin dose modificationsa

Risk factor Rosuvastatin dose modifications
Asian ethnicity (having either Filipino, Chinese, Japanese, Korean, Vietnamese or Asian-Indian origin) Start with 5 mg per day. Use caution with doses up to 20 mg per day. Do not use the 40 mg dose.
Severe renal impairment (creatinine clearance < 30 mL/min)b Start with 5 mg per day. Do not exceed 10 mg per day.
Severe hepatic impairmentb Start with 5 mg per day. Use caution with doses above 10 mg per day.
Advanced age (older than 70 years)b Start with 5 mg per day.
Concomitant medicines which inhibit the transporter proteins that rosuvastatin depends on (eg, OATP1B1 and BCRP), such as ciclosporin, ticagrelor and certain protease inhibitors Start with 5 mg per day with concomitant medicines that increase rosuvastatin AUC by 2-fold or higher. Refer to the data sheet for further guidance.
Genetic polymorphisms such as SLCO1B1 (OATP1B1) c.521CC or ABCG2 (BCRP) c.421AA genotype No starting dose recommended in the data sheet. However, do not exceed 20 mg per day.

Source: A. Menarini New Zealand Pty Ltd. 2026. Crestor New Zealand Data Sheet 4 May 2026. URL: www.medsafe.govt.nz/datasheet/c/Crestortab.pdf (accessed 29 June 2026).

Notes:

  1. List is not comprehensive – refer to the rosuvastatin data sheet for further information.
  2. The Crestor data sheet was recently updated with a recommendation to initiate rosuvastatin with a dose of 5 mg per day in patients with severe renal or hepatic impairment (this was previously 10 mg per day). The starting dose recommendation of 5 mg per day in elderly patients (over 70 years of age) is new.

When is it appropriate to use high dose rosuvastatin?

Only use the 40 mg per day dose in patients that still have severe hypercholesterolaemia and high cardiovascular risk despite treatment with 20 mg per day. Specialist supervision is recommended if a 40 mg daily dose is being considered.1

In addition to the patients with risk factors listed in Table 1, do not use the 40 mg dose in patients:1

  • with a previous history of muscular toxicity with another HMG-CoA reductase inhibitor or fibrate
  • with a personal or family history of hereditary muscular disorders
  • who abuse alcohol
  • with hypothyroidism
  • who are being treated with fibrates.

References

  1. A. Menarini New Zealand Pty Ltd. 2026. Crestor New Zealand Data Sheet 4 May 2026. URL: www.medsafe.govt.nz/profs/datasheet/c/Crestortab.pdf (accessed 29 June 2026).
  2. bpacnz. 2022. Rosuvastatin: Another Option to Lower Cardiovascular Disease Risk February 2022. URL: https://bpac.org.nz/2022/rosuvastatin.aspx (accessed 29 June 2026).
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