To the Editor—From July 2022 to April 2023, the Hong Kong Poison Information Centre has recorded six cases of severe rhabdomyolysis associated with prescription of high-dose rosuvastatin (≥40 mg daily). All patients were Chinese and presented with a mean creatine kinase concentration of approximately 15 000 IU/L. All except one patient developed acute kidney injury and three required temporary renal replacement therapy. Concomitant liver injury was also evident in three patients. Although statin treatment is associated with development of rhabdomyolysis, the reported incidence is rare at 0.44 per 10 000 person-years.1 Nonetheless Asian patients possess pharmacogenetic factors placing them at high risk. It has been reported that Chinese subjects had a plasma rosuvastatin level 2.3 times that of white subjects, despite being prescribed the same dose.2 Other risk factors include advanced age, hypothyroidism, alcohol abuse, poor renal function, vitamin D deficiency, diabetes mellitus, and drug-drug interactions. The recent clustering of six cases raised concerns about the safety of high-dose rosuvastatin in the Hong Kong population.

In mainland China, the recommended maximum daily dose of rosuvastatin is only 20 mg. It should also be noted that when product inserts of Crestor (rosuvastatin calcium) were revised in 2022 in the United Kingdom,3 Australia4 and Canada,5 Asian ethnicity was a contraindication for prescription of Crestor 40 mg per day. Both prescribers and pharmacists should be aware of this change and doctors should be warned of the increased vulnerability of Chinese and other Asian patients. The licenced dose of rosuvastatin in Hong Kong may need to be revised urgently.

The author had full access to the data, contributed to the study, approved the final version for publication, and takes responsibility for its accuracy and integrity.

The author has disclosed no conflicts of interest.

This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Graham DJ, Staffa JA, Shatin D, et al. Incidence of hospitalized rhabdomyolysis in patients treated with lipid-lowering drugs. JAMA 2004;292:2585-90. Crossref

2. Lee E, Ryan S, Birmingham B, et al. Rosuvastatin pharmacokinetics and pharmacogenetics in white and Asian subjects residing in the same environment. Clin Pharmacol Ther 2005;78:330-41. Crossref

3. Crestor film-coated tablets (package insert). London: AstraZeneca UK Ltd; 2022.

4. Crestor (rosuvastatin calcium) film-coated tablets (package insert). Chatswood: Menarini Australia Pty Ltd; 2022.

5. Crestor (rosuvastatin calcium tablets) [package insert]. Mississauga: AstraZeneca Canada Inc; 2022.