Rosuvastatin: a highly potent statin for the prevention and management of coronary artery disease

Prior statin therapy and 30-day mortality in South Korean patients with acute respiratory distress syndrome

BACKGROUND

The effect of prior statin therapy on mortality in patients with acute respiratory distress syndrome (ARDS) remains controversial. This study aimed to investigate whether prior statin therapy was associated with lower 30-day mortality compared to non-statin use.

METHODS

This population-based cohort study used nationwide data procured from the National Health Insurance service in South Korea, and included all the adult patients admitted to a hospital for ARDS treatment between January 1, 2013 and December 31, 2017.

RESULTS

In total, 14,600 patients with ARDS were included: 4,319 were statin users and 10,281 were non-statin users. After propensity score matching, 6,046 patients with ARDS (3,023 patients in each group) were included in the analysis. The 30-day mortality of statin users was 44.4% (1,331 of 3,023), while that of non-statin users was 45.2% (1,331 of 3,023). On Cox regression analysis in the propensity score matched cohort, 30-day mortality was not significantly associated with statin use compared to non-statin use (hazard ratio: 0.95, 95% confidence interval: 0.88 to 1.02; P = .165). On Kaplan-Meier estimation, the median survival time in statin users was 45 days (95% CI: 39 to 50), while that in non-statin users was 42 days (95% CI: 37 to 47) after propensity score matching, and there was no statistical difference with the log-rank test (P = .215).

CONCLUSION

This population-based cohort study in South Korea showed that prior statin therapy was not significantly associated with 30-day mortality in patients with ARDS. Our findings should be confirmed in future prospective studies.

Response surface optimization of biocompatible elastic nanovesicles loaded with rosuvastatin calcium: enhanced bioavailability and anticancer efficacy

Statins are mainly used for the treatment of hyperlipidemia, but recently, their anticancer role was extremely investigated. The goal of this study was to statistically optimize novel elastic nanovesicles containing rosuvastatin calcium to improve its transdermal permeability, bioavailability, and anticancer effect. The elastic nanovesicles were composed of Tween® 80, cetyl alcohol, and clove oil. The nanodispersions were investigated for their entrapment efficiency, particle size, zeta potential, polydispersity index, and elasticity. The optimized elastic nanovesicular dispersion is composed of 20% cetyl alcohol, 53.47% Tween 80, and 26.53% clove oil. Carboxy methylcellulose was utilized to convert the optimized elastic nanovesicular dispersion into elastic nanovesicular gels. Both the optimized dispersion and the optimized gel (containing 2% w/v carboxymethylcellulose) were subjected to in vitro release study, scanning and transmission electron microscopy, histopathological evaluation, and ex vivo permeation. The cell viability assay of the optimized gel on MCF-7 and Hela cell lines showed significant antiproliferative and potent cytotoxic effects when compared to the drug gel. Moreover, the optimized gel accomplished a significant increase in rosuvastatin bioavailability upon comparison with the drug gel. The optimized gel could be considered as a promising nanocarrier for statins transdermal delivery to increase their systemic bioavailability and anticancer effect. Graphical abstract.

Preadmission Statin Use and 90-day Mortality in the Critically Ill

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

This study aimed to examine the association between preadmission statin use and 90-day mortality in critically ill patients and to investigate whether this association differed according to statin type and dose. We hypothesized that preadmission statin use was associated with lower 90-day mortality.

Methods

This retrospective cohort study analyzed the medical records of all adult patients admitted to the intensive care unit in a single tertiary academic hospital between January 2012 and December 2017. Data including preadmission statin use, statin subtype, and daily dosage were collected, and the associations between these variables and 90-day mortality after intensive care unit admission were examined. The primary endpoint was 90-day mortality.

Results

A total of 24,928 patients (7,396 statin users and 17,532 non–statin users) were included. After propensity score matching, 5,354 statin users and 7,758 non–statin users were finally included. The 90-day mortality rate was significantly higher in non–statin users (918 of 7,758; 11.8%) than in statin users (455 of 5,354; 8.5%; P < 0.001). In Cox regression analysis, the 90-day mortality rate was lower among statin users than among non–statin users (hazard ratio: 0.70, 95% CI: 0.63 to 0.79; P < 0.001). Rosuvastatin use was associated with 42% lower 90-day mortality (hazard ratio: 0.58, 95% CI: 0.47 to 0.72; P < 0.001). There were no specific significant differences in the association between daily statin dose and 90-day mortality. In competing risk analysis, the risk of noncardiovascular 90-day mortality in statin users was 32% lower than that in non–statin users (hazard ratio: 0.68, 95% CI: 0.60 to 0.78; P < 0.001). Meanwhile, cardiovascular 90-day mortality was not significantly associated with statin use.

Conclusions

Preadmission statin use was associated with a lower 90-day mortality. This association was more evident in the rosuvastatin group and with noncardiovascular 90-day mortality; no differences were seen according to daily dosage intensity.

SIRT1/Atg5/autophagy are involved in the antiatherosclerosis effects of ursolic acid

The purpose of this study was to investigate the antiatherosclerosis effects of ursolic acid (UA) in high-fat diet-fed quails (Coturnix coturnix) and potential mechanism. Quails were treated with high-fat diet (14 % pork oil, 1 % cholesterol w/w) with or without UA (50, 150, or 300 mg/kg/day) for 10 weeks. Serum lipid profile was assessed at 0, 4.5, and 10 weeks. After 10 weeks, serum antioxidant status and morphology of aorta were assessed. Additionally, human umbilical vein endothelial cells (HUVECs) were exposed to 100 μg/ml oxidized low-density lipoprotein (ox-LDL) for 24 h, with or without pretreatment with UA (5, 10 or 20 μM) for 16 h, autophagy inhibitor 3-MA 5 mM for 2 h, or SIRT1 inhibitor EX-527 10 μM for 2 h. Cell viability and oxidative stress status were assessed and autophagy status was determined. Acetylation of lysine residue on Atg5 was assessed with immunoprecipitation. In results, high-fat diet negatively affected serum lipid profile and antioxidant status in quails and induced significant histological changes. Cotreatment with UA remarkably alleviated such changes. In HUVECs, ox-LDL treatment induced significant cytotoxicity along with oxidative stress, while UA cotreatment alleviated such changes significantly. UA treatment induced autophagy, enhanced SIRT1 expression, and decreased acetylation of lysine residue on Atg5. Cotreatment with 3-MA or EX-527 effectively abolished UA's protective effects. In summary, UA exerted antiatherosclerosis effects in quails and protected HUVECs from ox-LDL induced cytotoxicity, and the mechanism is associated with increased SIRT1 expression, decreased Atg5 acetylation on lysine residue, and increased autophagy.

Clinical utility of rosuvastatin and other statins for cardiovascular risk reduction among the elderly

Age is one of the strongest predictors of cardiovascular disease (CVD) risk. Treatment with statins can significantly reduce CVD events and mortality in both primary and secondary prevention. Yet despite the high CVD risk among the elderly, there is underutilization of statins in this population (ie, the treatment-risk paradox). Few studies have investigated the use of statins in the elderly, particularly for primary prevention and, as a result, guidelines for treating the elderly are limited. This is likely due to: uncertainties of risk assessment in older individuals where the predictive value of individual risk factors is decreased; the need to balance the benefits of primary prevention with the risks of polypharmacy, health care costs, and adverse medication effects in a population with decreased life expectancy; the complexity of treating patients with many other comorbidities; and increasingly difficult social and economic concerns. As life expectancy increases and the total elderly population grows, these issues become increasingly important. JUPITER (Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) is the largest primary prevention statin trial to date and enrolled a substantial number of elderly adults. Among the 5695 JUPITER participants ≥ 70 years of age, the absolute CVD risk reduction associated with rosuvastatin was actually greater than for younger participants. The implications of this JUPITER subanalysis and the broader role of statins among older adults is the subject of this review.

Rosuvastatin, inflammation, C-reactive protein, JUPITER, and primary prevention of cardiovascular disease--a perspective

The major public health concern worldwide is coronary heart disease, with dyslipidemia as a major risk factor. Statin drugs are recommended by several guidelines for both primary and secondary prevention. Rosuvastatin has been widely accepted because of its efficacy, potency, and superior safety profile. Inflammation is involved in all phases of atherosclerosis, with the process beginning in early youth and advancing relentlessly for decades throughout life. C-reactive protein (CRP) is a well-studied, nonspecific marker of inflammation which may reflect general health risk. Considerable evidence suggests CRP is an independent predictor of future cardiovascular events, but direct involvement in atherosclerosis remains controversial. Rosuvastatin is a synthetic, hydrophilic statin with unique stereochemistry. A large proportion of patients achieve evidence-based lipid targets while using the drug, and it slows progression and induces regression of atherosclerotic coronary lesions. Rosuvastatin lowers CRP levels significantly. The Justification for Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) trial was designed after the observation that when both low density lipoprotein and CRP were reduced, patients fared better than when only LDL was lowered. Advocates and critics alike acknowledge that the benefits of rosuvastatin in JUPITER were real. After a review, the US Food and Drug Administration extended the indications for rosuvastatin to include asymptomatic JUPITER-eligible individuals with one additional risk factor. The American Heart Association and Centers of Disease Control and Prevention had previously recognized the use of CRP in persons with "intermediate risk" as defined by global risk scores. The Canadian Cardiovascular Society guidelines went further and recommended use of statins in persons with low LDL and high CRP levels at intermediate risk. The JUPITER study focused attention on ostensibly healthy individuals with "normal" lipid profiles and high CRP values who benefited from statin therapy. The backdrop to JUPITER during this period was an increasing awareness of a rising cardiovascular risk burden and imperfect methods of risk evaluation, so that a significant number of individuals were being denied beneficial therapies. Other concerns have been a high level of residual risk in those who are treated, poor patient adherence, a need to follow guidelines more closely, a dual global epidemic of obesity and diabetes, and a progressively deteriorating level of physical activity in the population. Calls for new and more effective means of reducing risk for coronary heart disease are intensifying. In view of compelling evidence supporting earlier and aggressive therapy in people with high risk burdens, JUPITER simply offers another choice for stratification and earlier risk reduction in primary prevention patients. When indicated, and in individuals unwilling or unable to change their diet and lifestyles sufficiently, the benefits of statins greatly exceed the risks. Two side effects of interest are myotoxicity and an increase in the incidence of diabetes.

Role of rosuvastatin in lipid-lowering therapy today

A statinok a lipidcsökkentő terápia során leggyakrabban használt gyógyszerek. Az egyik leghatékonyabb statin a rosuvastatin, amely jól tolerálható és a primer, valamint a szekunder prevencióban lévő betegek többségében képes az LDL-koleszterint célértékig csökkenteni. Emellett a rosuvastatin mérsékli a triglicerid és a nagy szenzitivitású C-reaktív protein szintjét, valamint emeli a HDL-koleszterin koncentrációját is. A képalkotó eljárásokkal végzett vizsgálatok igazolták, hogy a rosuvastatinterápia nemcsak az atherosclerosis progresszióját csökkenti, hanem annak regressziójához is vezethet.

The JUPITER and AURORA clinical trials for rosuvastatin in special primary prevention populations: perspectives, outcomes, and consequences

Statins have emerged at the forefront of preventive cardiology and have significantly reduced cardiovascular events and mortality. Nonetheless, cardiovascular disease remains the leading cause of death in the United States and in other developed countries, as well as the etiology of significant morbidity and health-care expenditure. In an attempt to reduce potentially missed opportunities for instituting preventive therapy, the JUPITER study (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) and the AURORA study (A Study to Evaluate the Use of Rosuvastatin in Subjects on Regular Hemodialysis: An Assessment of Survival and Cardiovascular Events) examined the effect of statins in two specific patient populations who currently do not meet the guidelines for statin treatment, but nonetheless, are at high cardiovascular risk. This review outlines the JUPITER and AURORA trials, interprets the data and significance of the results, analyses the drawbacks and impact of both trials and delineates the potential for further clinical trials.

Effects of low-dose atorvastatin and rosuvastatin on plasma lipid profiles: a long-term, randomized, open-label study in patients with primary hypercholesterolemia

BACKGROUND AND OBJECTIVE

Despite the favorable effects of reduction of low-density lipoprotein-cholesterol (LDL-C) levels in decreasing the risk of coronary heart disease, many patients treated with lipid-lowering HMG-CoA reductase inhibitors (statins) do not achieve goal LDL-C levels. This may be due to high doses of statins prescribed that could potentially induce adverse effects and compromise patient safety and compliance with considerable expense in the long-term. We compared the actions of rosuvastatin and atorvastatin, administered at the low dosages of 10 and 20 mg/day, respectively, in reducing plasma LDL-C levels and their effects on other components of the atherogenic lipid profile in patients with primary hypercholesterolemia.

METHODS

In this randomized, parallel group, open-label clinical study, 106 patients with LDL-C >200 mg/dL were treated with rosuvastatin 10 mg/day (group A; n = 52), or atorvastatin 20 mg/day (group B; n = 54) for 48 weeks.

RESULTS

At 48 weeks, rosuvastatin 10 mg/day was associated with a significantly greater reduction in plasma LDL-C levels compared with atorvastatin 20 mg/day (-44.32% vs -30%; p < 0.005). Compared with atorvastatin, rosuvastatin also produced a greater reduction in plasma total cholesterol, triglycerides, and non-high-density lipoprotein-cholesterol (non-HDL-C) levels (p < 0.005). Plasma HDL-C levels were not affected significantly, independent of the drug used.

CONCLUSION

In high-risk patients with primary hypercholesterolemia, rosuvastatin 10 mg/day was more efficacious than atorvastatin 20 mg/day in reducing plasma LDL-C levels, enabling goal LDL-C levels to be achieved and improving other lipid parameters. Both treatments were well tolerated over 48 weeks.

Pharmacokinetic properties of rosuvastatin after single-dose, oral administration in Chinese volunteers: a randomized, open-label, three-way crossover study

BACKGROUND

Rosuvastatin, a 3-hydroxy-3-methyl glutaryl coenzyme A reductase inhibitor ("statin"), has been marketed for the treatment of patients with dyslipidemia.

OBJECTIVES

The objective of this study was to assess the dose proportionality and pharmacokinetic (PK) properties of rosuvastatin after single-dose administration in Chinese volunteers. The effects of food and sex on the PK properties of rosuvastatin in these volunteers were also assessed.

METHODS

This single-dose, randomized, open-label, 3-way crossover trial was conducted at West China Second University Hospital, Sichuan University, Chengdu, People's Republic of China. Healthy, male and female, adult (aged 20-24 years), Han Chinese volunteers were enrolled. Volunteers were allocated to receive, in randomized order according to a computer-generated randomization schedule, single doses of rosuvastatin (5, 10, and 20 mg) administered in separate trial periods, with a 1-week washout between periods. PK properties (C(max), T(max), AUC(0-t), apparent elimination t(1/2)) and tolerability were assessed immediately before (0 hour) and at 0.5, 1, 1.5, 2, 3, 4, 5, 6, 8, 12, 15, 24, 36, 48, and 72 hours after study drug administration. The Student-Newman-Keuls test was used to test for linearity. The effects of food intake and sex on the PK properties of rosuvastatin were also investigated in subanalyses using standardized meals and the t test of logarithm-transformed (lg) values to detect differences in C(max) and AUC(0-t) between sexes and between the fed (test) and fasted (reference) states. All of the results were corrected for dose by weight (mg/kg).

RESULTS

The study enrolled 12 healthy Chinese volunteers (6 men: mean [SD] age, 22.3 [1.5] years; mean [SD] weight, 61.8 [2.4] kg [range, 59-64 kg]; 6 women: mean [SD] age, 21.6 [1.4] years; mean [SD] weight, 56.4 [6.4] kg [range, 50-64 kg]). Geometric mean (SD) C(max) values of 10.22 (8.05), 25.86 (18.77), and 44.99 (17.99) ng/mL were achieved at a median T(max) of 2.5 hours after administration of single doses of 5, 10, and 20 mg of rosuvastatin, respectively; the corresponding geometric mean (SD) values of AUC(0-t) were 73.67 (48.78), 210.21 (178.70), and 303.81 (193.29) ng/mL . h(-1), and the mean (SD) apparent elimination t(1/2) values were 13.01 (8.68), 13.33 (5.21), and 15.40 (5.43) hours after administration. The Student-Newman-Keuls test results found that C(max) and AUC(0-t) were both linearly related to dose. In men, the mean (SD) C(max) values were 7.57 (6.49), 20.43 (14.10), and 36.80 (15.64) ng/mL, and the mean (SD) AUC(0-t) values were 51.74 (33.92), 136.35 (97.18), and 232.25 (101.66) ng/mL x h(-1), with the 5-, 10-, and 20-mg doses of rosuvastatin, respectively. In women, the corresponding C(max) values were 13.40 (9.27), 32.44 (23.10), and 54.82 (16.78) ng/mL, and AUC(0-t) values were 99.99 (54.07), 298.85 (223.66), and 430.21 (194.61) ng/mL x h-1. Results of the t tests of (lg)C(max) and (lg)AUC(0-t) found no significant differences between the male and female groups. However, C(max) and AUC(0-t) values of 0.82 ng/mL and 6.87 ng/mL x h-1, respectively, after oral administration of 10 mg of rosuvastatin in the fed state were significantly different from the corresponding values under fasting conditions (both, P < 0.05). Two adverse events (pharyngitis and nausea) were reported in 3 subjects (2 women, 1 man) at the 20-mg fasting state. Two cases of elevated laboratory values (bilirubin, from 16.1 micromol/L at baseline to 31.4 micromol/L; phosphocreatine, from 141 U/L at baseline to 307 U/L) were found at the poststudy follow-up immediately after study completion in 2 volunteers (1 man, 1 woman) at the 10-mg fed state; both values had returned to normal 5 days later.

CONCLUSIONS

The PK properties of rosuvastatin are based on first-order kinetics in the dose range tested. In this small, selected group of healthy Chinese volunteers, no clinically significant differences in PK properties between doses or sexes were found. The absorption of rosuvastatin was significantly decreased in the fed state compared with the fasting state, which suggests that rosuvastatin should be administered on an empty stomach. All rosuvastatin doses tested were well tolerated.