CVS Health CEO Karen Lynch has stepped down with company shares sinking 19% this year and the health care giant struggling on several fronts.

Company shares tumbled early Friday after CVS Health also said its third-quarter earnings will come in well below Wall Street expectations.

Lynch will be replaced by CVS executive David Joyner, who will attempt to steer the company through rising costs to its health insurance business, slumping drugstore sales and growing investor pressure. All major pharmacy chains are attempting to navigate a drastically changed landscape, facing competition online and elsewhere.

Leerink Partners analyst Michael Cherny said the leadership change was unexpected, though he understood the rationale behind it “following another quarter of underperformance.”

“It is hard, given the operational and stock underperformance, to say a change at the top is undeserved,” he said in a research note.

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