Statins are a popular cholesterol-reducing medication, but come with a risk of muscle aches and other uncomfortable side effects.
New research finds that bempedoic acid may be an effective alternative for people who can’t take statins or don’t want to take statins.
Experts recommend talking with your doctor about your treatment options.
For years, statins have been a mainstay of treatment for lowering cholesterol and reducing the risk of complications of heart disease. But, while they’re effective, they can come with intense side effects like muscle pain.
Now, a large new study published in the New England Journal of Medicine shows that another medication called bempedoic acid may be a good alternative for people who either can’t take statins or won’t take them because of the side effects.
The study looked at 13,970 patients from 32 countries who didn’t want to take statins, largely due to musculoskeletal pain. The study participants were randomly split into two groups—one was treated with bempedoic acid, and the other was given a placebo. They were then followed for up to five years.
At the end of the trial, the researchers found that people tolerated bempedoic acid well, and that there was a nearly 22% greater reduction in LDL (“bad”) cholesterol in the bempedoic acid group compared to those who took a placebo. There was also a 13% lower chance of experiencing cardiovascular events, including death, stroke, and heart attack, in the group that took bempedoic acid than those who took the placebo.
It’s important to point out that the study didn’t directly compare bempedoic acid to statins. However, it has plenty of people talking about bempedoic acid as an alternative to statins. Here’s what you need to know.
What is bempedoic acid?
Bempedoic acid (Nexletol) is a medication that’s designed to help patients who either can’t take statins or don’t want to take them. It was approved by the Food and Drug Administration (FDA) in 2020 to treat these patients, its impact at the time on serious complications from heart disease hadn’t been studied. In fact, the FDA required the drug’s label to read, “the effect of Nexletol on cardiovascular morbidity and mortality has not been determined.”
Bempedoic acid works to help lower levels of LDL (“bad”) cholesterol in the blood. It specifically targets an enzyme called adenosine triphosphate-citrate lyase (ACL) and, “as a result, inhibits production of cholesterol in the body, explains Jamie Alan, Ph.D., an associate professor of pharmacology and toxicology at Michigan State University.
It works a little differently than statins. “It targets the cholesterol biosynthesis pathway in the liver at a step earlier than that targeted by statins,” says Emily Aboujaoude, Pharm.D., clinical assistant professor at the Rutgers University, Ernest Mario School of Pharmacy.
Bempedoic acid side effects
Like all medications, bempedoic acid comes with its own risk of side effects. The following are the most common side effects of taking bempedoic acid, according to the Nexletol website:
Symptoms of the common cold or flu
Pain in the legs or arms
Overall, though, bempedoic acid is activated in your liver, so it’s unlikely to cause muscle aches the way statins do, Alan says.
Bempedoic acid vs. statins
Statins are drugs used to lower cholesterol, and they interfere with the production of cholesterol in your liver, according to Medline Plus. They specifically work to lower LDL cholesterol and raise HDL (“good”) cholesterol to help slow the formation of plaques in your arteries that could build up and lead to heart attack or stroke.
“Statins right now are considered the gold standard” of cholesterol-lowering medication, Alan says. They’re also an incredibly popular choice: 93% of adults using a cholesterol-lowering medication use a statin, according to the Centers for Disease Control and Prevention (CDC).
But, while statins are often effective, they have limitations. They can cause side effects like muscle pain, increased blood sugar, brain fog, and even liver damage, according to Penn Medicine.
Statins and bempedoic acid “have a different mechanism of action,” Alan says. While both statins and bempedoic acid work in your liver, “the target of bempedoic acid is mostly restricted to the liver; The target of statins is also in the muscle as well as in the liver,” Alan says.
That, she explains, is why there can be muscle aches and pains as a side effect with statins.
So, should bempedoic acid replace statins?
Not necessarily. This study didn’t compare bempedoic acid and statins directly, and statins are still considered the gold standard of care in reducing cholesterol. “However many patients are intolerant of [statins’] drug class due to the muscle pain associated with it,” Aboujaoude says. “Having an alternative to statins would benefit those patients and allow them to achieve their target cholesterol levels while avoiding the undesirable muscle symptoms.”
The latest study findings have “impressive” results, says Jennifer Wong, M.D., cardiologist and medical director of Non-Invasive Cardiology at MemorialCare Heart and Vascular Institute at Orange Coast Medical Center in Fountain Valley, Calif. “There are a lot of other medications out there that lower cholesterol that have really struggled to show there was a drop in adverse cardiovascular events when taken alone,” she says. “This study shows that, when taken alone, there was a decrease with bempedoic acid. However, the degree of decrease still is not nearly as impressive as with statins.”
Dr. Wong says she would still recommend that her patients try statins first. “We still have much more evidence and experience with statin drugs—they are always our first choice,” she says. “But, if somebody absolutely cannot tolerate statins. this would be one of the other medications we can turn to as an alternative. It may not have as much benefit, but is a good alternative.”
Rigved Tadwalkar, M.D., a board certified cardiologist at Providence Saint John’s Health Center in Santa Monica, Calif., agrees. “With statin therapy, we can see an up to 40 to 50% reduction in LDL cholesterol,” he says. “This is, in fact, still an alternative to statins but it's not quite as robust as statin therapy. We still try to keep patients on statin therapy, even at low doses.”
Ultimately, Alan says, this is a conversation to have with your prescribing doctor. “Statins are no longer the only game in town,” Alan says. “There are several other options that can be used to reduce cholesterol.”
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