Bempedoic Acid: An Emerging Therapy for Uncontrolled Low-Density Lipoprotein (LDL) Cholesterol

Abstract

Atherosclerotic cardiovascular disease (ASCVD) is a silent epidemic, which is progressing relentlessly across the globe. Developing countries such as India have a high prevalence of dyslipidemia and consequently a huge burden of coronary artery disease (CAD) and ASCVD. Low-density lipoprotein is regarded as the primary culprit in the genesis of ASCVD, and statins are the first line therapy for LDL-C lowering. Statin therapy has unequivocally demonstrated the benefit of lowering LDL-C in patients across the spectrum of CAD and ASCVD. Muscle symptoms and worsening of glycemic homeostasis could be challenges with statin therapy, especially with the use of high doses. A large fraction of patients are also unable to achieve their LDL goals with statins alone in clinical practice. Moreover, LDL-C goals have become aggressive over years, necessitating a combination of lipid lowering therapies. PCSK-9 inhibitors and Inclisiran have emerged as robust and safe lipid-lowering agents, but parenteral administration and high cost precludes their widespread use. Bempedoic acid is a novel lipid-lowering agent working upstream of statins by inhibiting the enzyme ATP citrate lyase (ACL). The drug produces an average LDL lowering of 22–28% in statin-naïve patients and 17–18% when given to preexisting statin users. Because skeletal muscles lack the ACL enzyme, there is minimal risk of muscle-related symptoms. In combination with ezetimibe, the drug synergistically reduced LDL-C by 39%. Moreover, the drug has no adverse effect on glycemic parameters and lowers hsCRP (inflammation) like statin. The series of four randomized CLEAR trials, involving >4000 patients, have shown consistent LDL lowering across the spectrum of ASCVD patients with or without background therapy. The large and only cardiovascular outcome trial of the drug (CLEAR Outcomes) has recently demonstrated a 13% reduction of MACE at 40 months. Rise in levels of uric acid (four times) and acute gout (three times) are more common compared to placebo with the drug, owing to competitive renal transportation by OAT 2. In a nutshell, Bempedoic acid represents a value addition to the inventory of dyslipidemia management.

Efficacy and outcomes of bempedoic acid versus placebo in patients with hypercholesterolemia: an updated systematic review and meta-analysis of randomized controlled trials

“…This activation procedure might aid in preventing the typical negative muscular effects of statin therapy [ 8 ]. BA has been recommended for approval by the food and drug administration and committee for medicinal products for human use for adults with primary hypercholesterolemia or mixed dyslipidemia, either as a supplement to diet and a statin or other lipid-lowering medications for those who cannot achieve LDL-C goals with a statin alone, as a standalone treatment, or in combination with other lipid-lowering therapies for statin-intolerant or contraindicated individuals [ 3 , 9 ]. It significantly decreased LDL-C, as well as additional relevant lipids and biomarkers in critical clinical trials when used alone or in combination with background lipid-lowering treatment [ 10 – 12 ].…”

Efficacy and Safety of Bempedoic Acid in Patients with Hyperlipidemia and Non-Alcoholic Fatty Liver Disease

“… 11 It effectively lowers LDL-C levels, along with other atherogenic lipid markers such as triglycerides and apolipoprotein B. 12 Additionally, the drug exhibits a robust anti-inflammatory effect by reducing high-sensitivity C-reactive protein (hsCRP) levels, further contributing to its potential cardiovascular benefits. 13 Given the importance of achieving specific LDL-C targets to reduce cardiovascular risk effectively, the combination of multiple cholesterollowering therapies has been proposed.…”