Rosuvastatin

Is rosuvastatin safe?

Yes, for most people who need it. Rosuvastatin, sold as Crestor, was the ninth most prescribed medicine in the United States in 2024, with about 53.7 million prescriptions for 14.4 million people (ClinCalc). It has no boxed warningBoxed warningThe strongest safety warning the US FDA puts on a medicine's label, printed inside a black border at the top.More in the glossary, no dependence and little danger in overdose. We score it 87, the same as atorvastatin.

The main catch is that rosuvastatin is potent, and its muscle risk climbs with dose. The label sets lower ceilings for three groups: people of Asian descent, people with severe kidney disease, and people taking certain other drugs. If you are in one of these groups, the dose on your box matters more than usual.

Muscle problems and the 40 mg dose

All statins can cause myopathy (muscle pain or weakness with raised CK, a muscle enzyme in the blood) and, rarely, rhabdomyolysis, in which damaged muscle releases proteins that can injure the kidneys. The 2026 US label says the myopathy risk is greater at 40 mg a day than at lower doses. Other risk factors it lists are age 65 or over, an underactive thyroid that is not controlled, kidney problems and some other cholesterol drugs.

In everyday terms, most aches in people on statins are not caused by the drug. In the JUPITER trial of 17,802 people, muscle aches were reported by 7.6% on rosuvastatin 20 mg and 6.6% on placebo. Unexplained muscle pain, tenderness or weakness, especially with fever, tiredness or dark urine, needs a doctor promptly.

Rosuvastatin has one quirk of its own. At 40 mg, trial patients more often had protein or traces of blood on urine dipstick tests. The label says this was generally temporary and did not come with worse kidney function.

Why Asian patients get a lower dose

In 2005, after a study found roughly twice the blood levels in Asian Americans compared with white volunteers, the FDA and Health Canada changed the advice. Health Canada's notice of 3 March 2005 named people of Filipino, Chinese, Japanese, Korean, Vietnamese or South Asian origin. The current US label still says to start Asian patients at 5 mg once a day and to weigh risks and benefits before going above 20 mg.

This came at the end of a rough start for the drug. Reports of muscle and kidney problems in 2003 and 2004 led to FDA advisories urging doctors to follow the label and to avoid 40 mg as a starting dose. Two decades later, with tens of millions of users, rosuvastatin's safety record at the recommended doses looks similar to other statins.

Rosuvastatin vs atorvastatin

The two are the most prescribed high-intensity statins, and the differences are small but real.

	Rosuvastatin	Atorvastatin
Usual adult range	5 to 40 mg once a day	10 to 80 mg once a day
Broken down by CYP3A4CYP450 enzymesA family of liver enzymes that break down many medicines. When another drug or supplement speeds them up or slows them down, drug levels change.More in the glossary	No	Yes
Grapefruit warning on US label	No	Yes, over 1.2 litres a day
Lower cap for Asian patients	Yes	No
New diabetes needing treatment (LODESTAR)	7.2%	5.3%
Cataract surgery (LODESTAR)	2.5%	1.5%

LODESTAR, published in the BMJ in 2023, randomised 4,400 Korean adults with coronary artery disease to one drug or the other for three years. Deaths, heart attacks, strokes and procedures were about equal (8.7% vs 8.2%). Rosuvastatin lowered LDL cholesterol a little more but came with more new diabetes and more cataract surgery. This was one open-label trial in one country, so it is a reason for discussion with your doctor rather than a reason to switch on your own.

Interactions to check

Because rosuvastatin does not rely on CYP3A4CYP450 enzymesA family of liver enzymes that break down many medicines. When another drug or supplement speeds them up or slows them down, drug levels change.More in the glossary, the common antibiotic and antifungal clashes that affect atorvastatin and simvastatin mostly do not apply. The drugs that matter work through other routes:

• Cyclosporine: raises rosuvastatin exposure about 7-fold. Maximum 5 mg a day.
• Gemfibrozil: avoid; if it cannot be avoided, start at 5 mg and do not exceed 10 mg.
• Some hepatitis C and HIV drugs: sofosbuvir/velpatasvir/voxilaprevir and ledipasvir/sofosbuvir should be avoided; several others cap the dose at 10 mg.
• Darolutamide, belumosudil: maximum 5 mg. Ticagrelor, febuxostat and fostamatinib: maximum 20 mg.
• Warfarin: rosuvastatin can raise INR, so the label asks for INR checks when starting, changing or stopping it.
• Antacids with aluminium and magnesium hydroxide: take rosuvastatin at least 2 hours before.

Red yeast rice contains a natural statin, so taking it on top of rosuvastatin doubles up on the same effect; see our red yeast rice page.

Who should be careful

• People of Asian descent, who should usually start at 5 mg.
• People with severe kidney disease not on dialysis: the label says start at 5 mg and do not exceed 10 mg.
• Anyone on cyclosporine, gemfibrozil, hepatitis C or HIV treatment, or warfarin.
• People with acute liver failure or decompensated cirrhosis, in whom it is contraindicatedContraindicationA situation in which a medicine should not be used, because the risk clearly outweighs any benefit, such as a known allergy to it.More in the glossary.
• Anyone pregnant, breastfeeding or planning a pregnancy.

If side effects bother you, talk to your doctor or pharmacist before stopping. Lower doses, alternate-day dosing or another statin are options a doctor can weigh.

How we scored it

Dependence (98), overdose marginOverdose marginHow far a normal dose is from a harmful one. A wide margin means an accidental extra dose is unlikely to cause serious harm.More in the glossary (92) and track record (93) are strong. Interactions (72) scores better than atorvastatin because grapefruit and the common CYP3A4CYP450 enzymesA family of liver enzymes that break down many medicines. When another drug or supplement speeds them up or slows them down, drug levels change.More in the glossary drugs are not a problem, while serious side effects (84) and regulatory warnings (85) reflect the dose-related muscle risk, the diabetes signal and the 2004 to 2005 advisories.