Rosuvastatin

Rosuvastatin
Systematic (IUPAC) name
(3R,5S,6E)-7-[4-(4-fluorophenyl)-2-(N-methylmethanesulfonamido)-6-(propan-2-yl)pyrimidin-5-yl]-3,5-dihydroxyhept-6-enoic acid
Identifiers
CAS number	287714-41-4
ATC code	C10AA07
PubChem	6439133
DrugBank	APRD00546
ChemSpider	393589
Chemical data
Formula	C22H28FN3O6S
Mol. mass	481.539
SMILES	eMolecules & PubChem
Pharmacokinetic data
Bioavailability	20%
Metabolism	Liver
Half life	19 hours
Excretion	Urine / Faeces
Therapeutic considerations
Pregnancy cat.	D(AU) X(US)
Legal status	Prescription Only (S4)(AU) POM(UK) ℞-only(US)
Routes	oral

Rosuvastatin is a member of the drug class of statins, used to treat high cholesterol and related conditions, and to prevent cardiovascular disease. Shionogi developed the product and the pharmaceutical company AstraZeneca markets it as Crestor.

Presentation

Rosuvastatin is available as Crestor in tablet form (5, 10, 20, or 40 mg) for oral administration. Tablets are pink, round or oval (40 mg), biconvex, film-coated, and imprinted with "ZD4522" and tablet strength.^[1] Japanese approval is in the dose range of 2.5 mg to 20 mg; therefore, smaller dose tablet forms might also be available outside the United States. Note that 97% of worldwide sales have been at or below the 20 mg dose.

Mechanism of action

Rosuvastatin is a competitive inhibitor of the enzyme HMG-CoA reductase, having a mechanism of action similar to other statins.^[2] Its approximate elimination half life is 19 hours and its time to peak plasma concentration are reached in 3–5 hours following oral administration.^[3]

Indications and regulation

Rosuvastatin is approved for the treatment of high LDL cholesterol (dyslipidemia), total cholesterol (hypercholesterolemia) and/or triglycerides (hypertriglyceridemia).^[1]

As of 2004, rosuvastatin had been approved in 154 countries and launched in 56. Approval in the United States by the FDA came on August 12, 2003.^[4]

In 2008, research emerged that rosuvastatin could reduce the risk of heart attack, stroke, and other vascular complications in patients with elevated C-reactive protein but no other risk factors.^[5] This could strongly impact medical practice by placing many patients on statin prophylaxis that otherwise would have been untreated.

The results of the JUPITER trial suggested that rosuvastatin may decrease the relative risk of heart attack and stroke in patients without hyperlipidemia.^[6]

The AURORA trial randomized 2776 patients undergoing hemodialysis to receive either rosuvastatin or placebo. The randomized, double-blind study found no difference in the two groups in the primary end point, a combination of cardiovascular mortality, nonfatal myocardial infarction, or nonfatal stroke. The study found no difference in all-cause mortality among this population at a mean follow up of 3.8 years. ^[7]

Effects on cholesterol levels

The effects of rosuvastatin on LDL cholesterol are dose-related. At the 10 mg dose, the average LDL cholesterol reduction was found to be 46% in one trial. Increasing the dose from 10 mg to 40 mg gave a modest increase of an additional 9% absolute reduction in LDL levels (55% below baseline levels).^[8]

Marketing and competition

Marketing

The drug was billed as a super-statin during its clinical development; the claim was that it offered high potency and improved cholesterol reduction compared to rivals in the class. The main competitors to rosuvastatin are atorvastatin (Lipitor), and the combination product ezetimibe/simvastatin (Zetia+Zocor, together marketed as Vytorin by Merck & Co.). However, people can also combine ezetimibe with either rosuvastatin or atorvastatin and other agents on their own, for somewhat similar augmented response rates. So far, some published information for comparing rosuvastatin, atorvastatin and ezetimibe/simvastatin results is available, but many of the relevant studies are still in progress.^[2]

First launched in 2003, sales of rosuvastatin were $129 million and $908 million in 2003 and 2004, respectively, with a total patient treatment population of >4 million by the end of 2004.^{[citation needed]} Typical per patient costs to the UK NHS are £18.03-26.02/month (compared to £0.85-1.37/month for simvastatin).

Debate & criticisms

In October 2003, several months after its introduction in Europe, Richard Horton, the editor of the medical journal The Lancet, criticised the way Crestor had been introduced. "AstraZeneca's tactics in marketing its cholesterol-lowering drug, rosuvastatin, raise disturbing questions about how drugs enter clinical practice and what measures exist to protect patients from inadequately investigated medicines," according to his editorial. The Lancet's editorial position is that the data for Crestor’s superiority relies too much on extrapolation from the lipid profile data (surrogate endpoints) and too little on hard clinical endpoints which are available for other statins which had been on the market longer. The manufacturer responded by stating that few drugs had been tested so successfully on so many patients. In correspondence published in The Lancet, AstraZeneca's CEO Sir Tom McKillop called the editorial "flawed and incorrect" and slammed the journal for making "such an outrageous critique of a serious, well-studied medicine."^[9]

In 2004, the consumer interest organisation Public Citizen filed a Citizen's Petition with the FDA asking that Crestor be withdrawn from the US market. On March 11, 2005, the FDA issued a letter to Sidney M. Wolfe, M.D. of Public Citizen both denying the petition and providing an extensive detailed analysis of findings which demonstrated no basis for concerns about rosuvastatin compared with the other statins approved for marketing in the United States.^[10].

Myopathy

As with all statins, there is a concern of rhabdomyolysis, a severe undesired side effect. The FDA has indicated that "it does not appear that the risk [of rhabdomyolysis] is greater with Crestor than with other marketed statins", but has mandated that a warning about this side effect, as well as a kidney toxicity warning, be added to the product label.^[11]

Notes

References

• "Annual Report and Form 20-F, Information 2004" (PDF). AstraZeneca PLC. 2005. http://www.astrazeneca.com/sites/7/imagebank/typearticleparam511562/astrazeneca-2004-annual-report.pdf. 
• "Annual Report and Form 20-F, 2003" (PDF). AstraZeneca PLC. 2004. http://www.astrazeneca.com/sites/7/imagebank/typearticleparam503063/AstraZeneca%20Annual%20Report%202003.pdf. Retrieved on 2005-03-20. 
• "Highlights of Prescribing Information" (PDF). AstraZeneca PLC. 2008. http://www1.astrazeneca-us.com/pi/crestor.pdf. Retrieved on 2009-03-11. 
• McTaggart F, Buckett L, Davidson R, Holdgate G, McCormick A, Schneck D, Smith G, Warwick M (2001). "Preclinical and clinical pharmacology of Rosuvastatin, a new 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor". Am J Cardiol 87 (5A): 28B–32B. doi:10.1016/S0002-9149(01)01454-0. PMID 11256847. 

External links

• Crestor web site, by AstraZeneca
• "Rosuvastatin (Crestor) Information". eMedicineHealth. 2005-10-16. http://www.emedicinehealth.com/rosuvastatin_crestor/article_em.htm.