Know How Bempedoic Acid Stacks Up to Other Non-Statins

Top Takeaways

• Bempedoic acid lowers LDL by another 20% or so when added to a statin.
• It’s costly and can raise uric acid levels and gout risk, but it doesn’t seem to cause myalgias.
• Statins remain first-line; reserve bempedoic acid for statin-intolerant patients or when an oral add-on is preferred.

You’ll hear buzz about bempedoic acid (Nilemdo), a new oral non-statin cholesterol med.

Bempedoic acid is the first “ATP citrate lyase inhibitor.” It blocks an earlier step in cholesterol synthesis in the liver compared to statins...and avoids the muscle activation that leads to myalgias.

Bempedoic acid lowers LDL another 20% or so when added to a max tolerated statin. It doesn’t have much impact on triglycerides or HDL.

New data show that bempedoic acid 180 mg daily prevents 1 CV event for every 63 patients at high CV risk treated for about 3 years.

But this study is in statin-intolerant patients or those who only tolerate a very low dose...such as atorvastatin 5 mg/day.

Be aware of downsides. Bempedoic acid costs about $140/month and it may increase the risk of statin-induced myopathy when added to a statin.

Plus it can bump up uric acid levels. About 1 in 100 patients on bempedoic acid report a gout attack...however most of these patients have a history of gout or prior elevated uric acid levels.

Continue to emphasize statins first for LDL lowering...based on established CV benefits, safety and tolerability, and low cost.

If needed, consider adding a non-statin for patients at high risk whose LDL remains above target despite a statin.

Usually lean toward adding ezetimibe (Ezetrol) first. It reduces CV events in some high-risk patients also on a statin...lowers LDL another 20% or so when added to a statin...and generics cost under $10/month.

Or suggest adding a PCSK9 inhibitor (alirocumab, evolocumab). These injectables reduce CV events in high-risk patients on a statin...and lower LDL another 50% or so. But they cost up to $680/month.

Consider icosapent ethyl (Vascepa) as another add-on option. It decreases CV events in high-risk patients on a statin who also have triglycerides over 1.5 mmol/L. But icosapent ethyl costs about $320/month.

Save bempedoic acid as an add-on option if a statin plus ezetimibe isn’t enough...and an oral med is preferred. But keep in mind there aren’t data yet to show improved CV outcomes when added to an optimized statin.

Don’t be surprised to see bempedoic acid used alone or as an add-on in patients with true statin intolerance. It doesn’t seem to cause myalgias.

For patients starting bempedoic acid, recommend monitoring uric acid and liver tests at baseline, then periodically thereafter...since bempedoic acid can increase liver enzymes in about 1 in 67 patients.

In general, recommend keeping simvastatin dosing to 20 mg or less if combined with bempedoic acid...and monitor for myopathy when combined with any statin.

Compare meds with our chart, Non-Statin Lipid-Lowering Agents.

• Chart: Non-Statin Lipid-Lowering Agents