Rosuvastatin vs Atorvastatin: Which to Take?

The short answer

Rosuvastatin (brand name Crestor) and atorvastatin (brand name Lipitor) are the two most powerful statins. Both lower LDL cholesterol (LDL-C), the "bad" cholesterol that builds plaque in artery walls. Both prevent heart attacks and strokes, and both are generic and inexpensive.

For many people, either is a good choice. They differ in four practical ways:

1. Strength per milligram. Rosuvastatin does more at a lower dose.
2. Kidneys. Atorvastatin needs no kidney dose change. Rosuvastatin does when kidney function is severely reduced.
3. Drug interactions. Atorvastatin is affected by medicines that block the liver enzyme CYP3A4. Rosuvastatin isn't, though it has interactions of its own.
4. Ancestry and genes. Rosuvastatin levels run higher in people of Asian ancestry and in people with certain gene variants, which changes the starting dose.

Dose ranges, kidney dosing, and Asian ancestry dosing are from the FDA labels for Crestor and Lipitor. Intensity groups are the standard ACC/AHA definitions (high intensity lowers LDL-C by 50% or more, moderate by 30 to 49%), first set out in the 2018 guideline.

How much each one lowers LDL

Rosuvastatin lowers LDL more per milligram: about 46% at 10 mg versus about 37% for atorvastatin 10 mg in the largest head-to-head comparison. Both reach a 50% or greater drop at their higher doses. The best head-to-head comparison is the STELLAR trial, which randomized about 2,400 adults with high LDL to different doses of four statins for 6 weeks. At the starting dose of 10 mg, rosuvastatin lowered LDL by about 46% and atorvastatin by about 37%. Across the whole dose range, rosuvastatin lowered LDL by an average of 8.2 percentage points more.

The FDA labels give each drug's own dose-response figures, from separate studies:

The starting dose does most of the work, and each step up adds a smaller extra drop, so going from a middle dose to the top dose often buys less than people expect. Because individual responses vary a lot, recheck your LDL (and ideally ApoB, part of advanced lipid testing) after starting to see how well your statin works.

Outcomes: does the stronger statin prevent more heart attacks?

No. At doses that lower LDL by a similar amount, the two prevent heart attacks and strokes about equally well, according to the largest head-to-head trial. Both drugs also have large placebo-controlled outcomes trials behind them, so each has proven that it works.

The best direct answer comes from LODESTAR, a randomized trial in South Korea of 4,400 adults with coronary artery disease, followed for three years. The results:

• Death, heart attack, stroke, or a procedure to reopen an artery: 8.7% with rosuvastatin vs 8.2% with atorvastatin, a difference that could easily be chance.
• Average LDL-C during treatment: about 70 mg/dL with rosuvastatin vs about 73 mg/dL with atorvastatin (1.8 vs 1.9 mmol/L).
• New diabetes needing medication: 7.2% vs 5.3%, higher with rosuvastatin.
• Cataract surgery: 2.5% vs 1.5%, higher with rosuvastatin.

LODESTAR has limits worth knowing. It was open label, meaning patients and doctors knew which drug was given. It enrolled only Korean adults, so results may not transfer exactly to other populations. Average doses were about 17 mg of rosuvastatin and 36 mg of atorvastatin. And the diabetes and cataract findings were secondary results that need confirming. Keep that in mind, especially if you're already close to diabetes.

An earlier trial, SATURN, used ultrasound inside the heart arteries to compare the top doses, rosuvastatin 40 mg and atorvastatin 80 mg, for two years. Rosuvastatin got LDL-C lower (about 63 vs 70 mg/dL), but both shrank plaque by a similar amount on the main measure, and most people on either drug had some plaque regression.

Overall, at doses that give similar LDL lowering, the two statins perform about the same. Reaching your LDL target and staying on treatment matter most.

Side effects

Rosuvastatin and atorvastatin have similar side effects overall, with a few differences in diabetes risk and dose-related muscle risk. Muscle aches are the side effect people worry about most, and for both drugs most aches blamed on the statin also show up on placebo in blinded trials. We cover that in detail in statin side effects: what's real.

Other differences:

• Muscle risk rises with dose and with blood levels for both. The rosuvastatin label notes higher myopathy risk at 40 mg than at lower doses.
• New diabetes. All statins raise blood sugar slightly, mostly in people already close to diabetes. LODESTAR found more new diabetes on rosuvastatin, though the doses weren't matched for LDL effect.
• Liver. Both labels list acute liver failure and decompensated cirrhosis as reasons not to use them. Mild liver enzyme rises can happen with either and are usually harmless.

Kidneys and liver

Atorvastatin needs no dose change for kidney disease, while rosuvastatin does when kidney function is severely reduced. Kidney disease is one of the clearest reasons to prefer one over the other. Atorvastatin is cleared almost entirely by the liver, and its label calls for no dose change in kidney disease. Rosuvastatin is partly cleared by the kidneys, so with severe kidney impairment (creatinine clearance below 30 mL/min) the label says to start at 5 mg and not exceed 10 mg. For someone with advanced chronic kidney disease who needs a high-intensity statin, atorvastatin is often the simpler choice.

Liver disease affects both drugs, and the decision depends on the specific condition and its severity. Work that out with your prescriber instead of applying a rule on your own.

Drug interactions

Atorvastatin interacts with medicines that block the liver enzyme CYP3A4, while rosuvastatin mostly doesn't but has its own transporter-related interactions. Here the two drugs differ most.

Atorvastatin is broken down partly by CYP3A4, a liver enzyme that many common medicines block. When that enzyme is blocked, atorvastatin levels rise. According to its label:

• With clarithromycin or itraconazole, don't go above 20 mg.
• With several HIV and hepatitis C medicines, limits range from 20 to 40 mg.
• With cyclosporine or gemfibrozil, the combination is not recommended.
• Grapefruit juice: avoid more than 1.2 liters a day.

Rosuvastatin isn't meaningfully affected by CYP3A4, so prescribers often choose it for people on medicines like diltiazem, verapamil, or amiodarone. It does interact with drugs that affect its transporters. According to its label:

• With cyclosporine, don't go above 5 mg.
• With gemfibrozil, start at 5 mg and don't go above 10 mg.
• With several HIV and hepatitis C medicines, start at 5 mg and don't go above 10 mg.
• With ticagrelor (a common blood thinner after a heart attack or stent), don't go above 20 mg.

Neither list is complete. Bring a full medication list, including supplements, to anyone prescribing a statin.

Genetics and ancestry

Genes affect blood levels of both drugs, and rosuvastatin a little more. SLCO1B1 matters for both, while ABCG2 and Asian ancestry matter mainly for rosuvastatin.

SLCO1B1 makes a transporter that carries statins into the liver. Reduced-function versions raise blood levels of both drugs. The CPIC guideline advises:

• Atorvastatin: with decreased function, start at 40 mg or less; with poor function, start at 20 mg or less and consider rosuvastatin or adding a non-statin medicine if more is needed.
• Rosuvastatin: with decreased function, the usual starting dose, with caution above 20 mg; with poor function, start at 20 mg or less.

ABCG2 affects rosuvastatin specifically. People with two copies of a reduced-function variant had about 144% higher rosuvastatin levels, so CPIC advises starting at 20 mg or less. The same variant also tends to give a bigger LDL drop.

Asian ancestry matters for rosuvastatin. The FDA label reports about twice the drug levels in Asian patients compared with White patients and recommends starting at 5 mg. The ABCG2 variant, which is about three times more common in East Asian populations than European ones, explains part of that difference.

The Dutch guideline found that the SLCO1B1 variant raises rosuvastatin and atorvastatin levels by a similar amount, and it recommends keeping either dose as low as possible (for example, by adding ezetimibe) in carriers who have other risk factors for muscle side effects.

We explain these genes and both guidelines in full in our statin pharmacogenomics guide.

Cost and convenience

Both are available as inexpensive generics, and both are taken once a day, at any time of day, with or without food. Cost is rarely the deciding factor between them.

Why choosing and dosing a statin takes judgment

Choosing well means matching the statin and dose to how far your LDL needs to fall, your other medicines, your kidneys, and your history. Picking between two generic pills looks simple on paper. A good choice weighs:

• How far your LDL needs to fall. Someone who needs a 60% drop may need a top-dose statin plus ezetimibe from the start. Someone who needs 30% may do well on a low dose.
• Your other medicines, especially heart medicines like diltiazem, amiodarone, or ticagrelor.
• Kidney function, checked with a blood test.
• Ancestry and, when available, gene results.
• Your history with statins, including which ones caused trouble and at what dose. If that history is complicated, see our statin intolerance program.
• Diabetes risk, which can tip the balance at higher doses.
• What happens next. If the statin dose that suits you isn't enough on its own, the next step is usually adding ezetimibe, then other options from our alternatives to statins guide.

How Preval Health helps

Preval's protocols, written by a board-certified preventive cardiologist, weigh your LDL and ApoB target, kidney function, medication list, ancestry, and statin history. Licensed clinicians in our partner telehealth network prescribe, and we repeat labs after each change so dosing follows your actual numbers.

If statins have caused problems for you, our statin intolerance program covers that. Optional longevity genetic testing, which includes the SLCO1B1 statin gene, is offered at the first visit. Preval runs as a cash practice.