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Cyclosporin: Co-administration of rosuvastatin with cyclosporin resulted in no significant changes in cyclosporin plasma concentration. However, rosuvastatin steady state AUC (0-t) increased up to 7-fold over that seen in healthy volunteers administered the same dose. Concomitant use of rosuvastatin and cyclosporin is contraindicated (see Table 4 as follows and Contraindications).
Protease inhibitors: Although the exact mechanism of interaction is unknown, concomitant protease inhibitor use may strongly increase rosuvastatin exposure (see Table 4 as follows). For instance, in a pharmacokinetic study, co-administration of 10 mg rosuvastatin and a combination product of two protease inhibitors (300 mg atazanavir/100 mg ritonavir) in healthy volunteers was associated with an approximately 3-fold increase in rosuvastatin AUC. The concomitant use of rosuvastatin and some protease inhibitor combinations may be considered after careful consideration of rosuvastatin dose adjustments based on the expected increase in rosuvastatin exposure (Table 4 as follows, Dosage & Administration and Precautions)
Gemfibrozil and other lipid-lowering products: Concomitant use of rosuvastatin and gemfibrozil resulted in a 2-fold increase in rosuvastatin Cmax and AUC (0-t). Based on data from specific interaction studies, no pharmacokinetic relevant interaction with fenofibrate is expected, however pharmacodynamic interaction may occur.
Gemfibrozil, fenofibrate, other fibrates and lipid lowering doses (≥ 1g/day) of niacin (nicotinic acid) increase the risks of myopathy when given concomitantly with HMG-CoA reductase inhibitors, probably because they can produce myopathy when given alone. Therefore, the dose of rosuvastatin should not exceed 10 mg/day when given in combination with fibrates or niacin (see Dosage & Administration and Precautions).
Antacid: The simultaneous dosing of rosuvastatin with an antacid suspension containing aluminium and magnesium hydroxide resulted in a decrease in rosuvastatin plasma concentration of approximately 50%. This effect was mitigated when the antacid was dosed 2 hours after rosuvastatin. The clinical relevance of this interaction has not been studied.
Erythromycin: Concomitant use of rosuvastatin and erythromycin resulted in a 20% decrease in AUC (0-t) and a 30% decrease in Cmax of rosuvastatin. This interaction may be caused by the increase in gut motility caused by erythromycin.
Cytochrome P450 enzymes: Results from in vitro and in vivo studies show that rosuvastatin is neither an inhibitor nor an inducer of cytochrome P450 isoenzymes. In addition, rosuvastatin is a poor substrate for these isoenzymes. Therefore, drug interactions resulting from cytochrome P450-mediated metabolism are not expected. No clinically relevant interactions have been observed between rosuvastatin and either fluconazole (an inhibitor of CYP2C9 and CYP3A4) or ketoconazole (an inhibitor of CYP2A6 and CYP3A4).
Interactions requiring rosuvastatin dose adjustments (see also Table 4): When it is necessary to co-administer rosuvastatin with other medicinal products known to increase exposure to rosuvastatin, doses of rosuvastatin should be adjusted. It is recommended that prescribers consult the relevant product information when considering administration of such products together with rosuvastatin. Start with a 5 mg once daily dose of rosuvastatin if the expected increase in exposure (AUC) is approximately 2-fold or higher.
The maximum daily dose of rosuvastatin should be adjusted so that the expected rosuvastatin exposure would not likely exceed that of the recommended maximum daily dose of rosuvastatin taken without interacting medicinal products.
For example, where the recommended dose of rosuvastatin is 20mg; the dose of rosuvastatin taken with a ritonavir/atazanavir combination (3.1-fold increase) should not exceed 5 mg, and the dose of rosuvastatin taken with gemfibrozil (1.9-fold increase) should not exceed 10 mg. (See Table 4.)
Click on icon to see table/diagram/imageEffect of rosuvastatin on co-administered medicinal products: Warfarin: As with other HMG-CoA reductase inhibitors, co-administration of rosuvastatin and warfarin may result in a rise in INR compared to warfarin alone. In patients taking vitamin K antagonists monitoring of INR is recommended both at initiation or cessation of therapy with rosuvastatin or following dose adjustment.
Oral contraceptive/hormone replacement therapy (HRT): Concomitant use of rosuvastatin and an oral contraceptive resulted in an increase in ethinyl oestradiol and norgestrel AUC of 26% and 34%, respectively. These increased plasma levels should be considered when selecting oral contraceptive doses. There are no pharmacokinetic data available in subjects taking concomitant rosuvastatin and HRT and therefore a similar effect cannot be excluded. However, the combination has been extensively used in women in clinical trials and was well tolerated.
Other medicinal products: Based on data from specific interaction studies, no clinically relevant interaction with digoxin is expected.
Endocrine function: Although clinical studies have shown that rosuvastatin alone does not reduce basal plasma cortisol levels or impairs adrenal reserve, caution should be exercised if any HMG-CoA reductase inhibitor or other lipid-lowering agent is administered concomitantly with drugs that may decrease levels or activity of endogenous steroid hormones (ketoconazole, spironolactone, cimetidine).
Fusidic Acid: Interaction studies with rosuvastatin and fusidic acid have not been conducted. As with other statins, muscle related events, including rhabdomyolysis, have been reported in post-marketing experience with rosuvastatin and fusidic acid given concurrently. Therefore, the combination rosuvastatin and fusidic acid is not recommended. If possible, temporary suspension of rosuvastatin treatment is recommended. If unavoidable, patients should be closely monitored.
