Bempedoic acid, a relatively new type of cholesterol medication marketed under the brand name Nexletol, has been getting a lot of attention lately. The drug was approved by the FDA in 2020 as an alternative to statin medications for reducing LDL cholesterol levels in the blood. The renewed attention is mainly due to a recent study revealing that it was not only effective at bringing cholesterol levels closer to the ideal level, but it also lowered the risk of a heart attack. This is good news for those who either can’t take statins or prefer not to.
Cholesterol 101
According to the CDC, high cholesterol affects nearly 2 out of every 5 adults in the United States, leaving them at greater risk of suffering heart attacks or strokes. Cholesterol is a waxy substance that is used in the production of both hormones and Vitamin D. Although cholesterol is necessary, an excess of cholesterol can stick to other substances in the blood, forming an amalgamation called plaque. Plaque gets stuck to the walls of the arteries and builds up, narrowing and eventually blocking the flow of blood.
There are two types of lipoproteins in cholesterol. These are high-density lipoprotein (HDL) which is considered “good” as it carries cholesterol from other parts of the body to the liver for removal, and low-density lipoprotein (LDL), which is considered “bad” as it is more likely to contribute to plaque buildup. Triglycerides, a type of fat in the blood, are also included when calculating cholesterol levels. Triglycerides store unused calories to use later, but excess triglycerides can lead to hardened arteries or an inflamed pancreas.
Genetic predisposition, underlying health conditions, lifestyle, and diet choices all play a role in overall cholesterol levels. Several lifestyle and diet choices can help to either increase the amount of HDL in the blood or decrease the amount of LDL, such as:
- Avoid drinking too much alcohol.
- Avoid sugary drinks.
- Eat more omega-3s.
- Eliminate trans fats.
- Increase physical activity.
- Lose excess body fat.
- Quit smoking.
- Reduce saturated fats.
The Problem with Statins
While lifestyle changes are the preferred method for reducing cholesterol levels, they often don’t reduce levels sufficiently. The most commonly prescribed type of medication for managing high cholesterol are statins, of which there are several. Statins work by blocking the production of an enzyme needed to make cholesterol. Common medications in this category include:
- Atorvastatin
- Fluvastatin
- Lovastatin
- Pitavastatin
- Pravastatin
- Rosuvastatin
- Simvastatin
Unfortunately, statin medications also have a few side effects that can make them less than ideal for some individuals. The most commonly cited side effects caused by statin medications range from merely uncomfortable to potentially fatal.
Muscle Pain
One of the most frequently reported side effects attributed to statins is muscle pain, which can range from mild discomfort to severe, constant aching. For the large majority of cases, muscle pain is symptomatic only. While uncomfortable, the soreness and muscle aches aren’t causing any real damage. In very rare situations, however, taking statins can lead to rhabdomyolysis, a serious disease that causes muscle pain, liver damage, and kidney failure. Out of all those taking statins, this disease only affects a few people per million, but due to its severity, individuals who experience unexplained muscle pain while taking a statin should contact a medical professional for further recommendations.
Liver Damage
Statins can sometimes increase the levels of enzymes in the liver, causing the liver to become inflamed. If the increase is mild, the patient may be able to continue taking the statin they started with. A more pronounced increase would lead to a change in medication, either to a new statin or one of the alternatives to statins like bempedoic acid. Tests to monitor liver function should be completed regularly to ensure any difficulties are caught early. If you experience unusual fatigue, weakness, loss of appetite, yellowing of the skin or eyes, excessively dark urine, or pain in the upper abdomen, contact a medical professional immediately.
Increased Blood Sugar
Statins can also lead to an increase in overall blood sugar. While the risk is small, it is important enough that the FDA has issued a warning on statin labels regarding the issue. In most cases, those who developed diabetes already had slightly elevated blood glucose levels before taking the statin.
Memory Loss or Confusion
There is limited evidence that some individuals have developed memory loss or confusion that has reversed when they stopped taking statins. On the other hand, there is also evidence that taking statins may actually decrease the risk of dementia and Alzheimer’s disease.
***While you should contact your doctor if you are experiencing any of these symptoms, you should not stop taking your medication without talking to them.
Interactions
In addition to the side effects often experienced by statin users, these medications interact with several other medications as well as some foods, particularly those with furanocoumarins. These interactions can cause the medication to be either diminished or amplified in efficacy. Statins may interact negatively with any of the following:
- Alcohol
- Amiodarone; treats arrhythmia
- Cyclosporine and similar immunosuppressant drugs
- Gemfibrozil; treats high cholesterol
- Grapefruit
- Limes
- Marmalade
- Pomello
- Red Yeast Rice
- Ritonavir, an HIV treatment
- Saquinavir, an HIV treatment
- Several cancer treatments
- Seville oranges
- Tangelos
- Various antibiotic and antifungal treatments
Bempedoic Acid as an Alternative
Like statins, bempedoic acid lowers the production of cholesterol in the liver by blocking an enzyme. It is as effective as statins at reducing the risk of dying via heart attack and nearly as effective at reducing the levels of cholesterol in the blood. Unlike statins, bempedoic acid is primarily metabolized in the liver rather than in peripheral tissues, so this medication does not cause the aches and pains that statin drugs often do. A recent analysis of several bempedoic acid trials also suggests that this medication is somewhat protective against the development or worsening of diabetes.
Taking bempedoic acid does not come without any risks, however. This drug may elevate uric acid and slightly increase the risk of developing gout. It is also possible that it may contribute to tendon rupture. This is especially true for those who have a history of tendon problems or have already experienced a rupture in the past.
Bempedoic acid does not have any interactions with the furanocoumarin compounds found in grapefruit and the like, either. It also has fewer interactions with other medications than statins do. While this medication can be used in conjunction with some statins, it should not be combined with either simvastatin or pravastatin. It also has not been evaluated for safety for at-risk groups such as those who are pregnant, breastfeeding, under 18, over 60, or have severe kidney or liver damage.
In Conclusion
Bempedoic acid is a beneficial medication for those looking to lower their blood cholesterol levels. Recent studies suggest its ability to protect people with high cholesterol from heart attack is equal to that of statins. Although it isn’t quite as effective at lowering cholesterol as statin drugs, it comes close, and it doesn’t trigger as many side effects. It is safer to use in conjunction with other medications than most statins, and it doesn’t interact with furanocoumarin-heavy foods. In addition, it can sometimes be used in conjunction with certain statins to further reduce cholesterol.
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