Combination therapy of bempedoic acid and PCSK9i reduces LDL-c further in hypercholesterolemia

Lipid lowering with bempedoic acid added to a proprotein convertase subtilisin/kexin type 9 inhibitor therapy: A randomized, controlled trial

Literature - Rubino J, MacDougall DE, Sterling LR, et al. - J Clin Lipidol. 2021, DOI:

Introduction and methods

Statins are the first-line therapy for lowering LDL-c. However, patients can be statin intolerant and fewer than half of eligible patients receive recommended high-intensity statin therapy [1-4]. Therefore, combination therapies with and without statins need to be explored.

Bempedoic acid is an ATP-citrate lyase inhibitor that significantly lowered LDL-c levels in patients with hypercholesterolemia as a single treatment or as adjunct to statins and/or ezetimibe [5-7]. Both bempedoic acid and PCSK9i results in upregulated levels of hepatic LDL receptors; bempedoic acid by increasing the expression of LDLR and PCSK9i by inhibiting the degradation of the receptor. Whether these two therapies combined might further reduce LDL-c has not been investigated yet.

This phase 2, randomized, double-blind, placebo-controlled, parallel-group study included patients with hypercholesterolemia from April 7, 2017, to January 29, 2018 from the United States. The study was conducted in three phases: 1) a 1.5 month screening/wash-out period with discontinuation of all LLTs, 2) a 3-month period in which patients initiated PCSK9i therapy (evolocumab 420 mg/3.5mL monthly injection), and 3) a 2-month period wherein patients were randomized (1:1) to bempedoic acid 180 mg once daily or placebo, while continuing PCSK9i background therapy. Eligible patients (n=59) had fasting LDL-c levels of ≥160 mg/dL prior to PCSK9i treatment and after wash-out of other LLT, and LDL-c levels of ≥70 mg/dL while receiving stable PCSK9i therapy prior to randomization. Patients with FH, hypertriglyceridemia, diabetes and known CVD, PAD or cerebrovascular disease were excluded. The primary endpoint was LDL-c percent change at 2 months after randomization. Secondary efficacy endpoints in the randomization phase included percent change from baseline to month 2 in ApoB, non-HDL-c, total cholesterol (TC), and hsCRP levels. The exploratory endpoints were percent change from baseline to month 2 in TG, Lp(a), and HDL-c levels. Also, safety and tolerability were assessed by adverse events.

Main results

  • Bempedoic acid therapy significantly reduced LDL-c levels after 2 months (-27.5% least square [LS] mean change from baseline) compared to placebo (2.8%). The difference in LS means between bempedoic acid and placebo treatment was -30.3% (95% CI: -41.3% to -19.2%, P<0.001).
  • After 1 month, 61.5% of patients who received bempedoic acid achieved their LDL-c goal of<70 mg/dL compared to none in the placebo group. After 2 months, 40.7% of bempedoic acid treated patients had LDL-c levels of <70 mg/dL vs. 3.8% in the placebo group.
  • Bempedoic acid treatment resulted in significant reductions of ApoB (P<0.001), non-HDL-c (P<0.001), TC (P<0.001), and hsCRP (P=0.029) levels compared to placebo. Percent changes of Lp(a), HDL-c, and TG were comparable between the treatment arms.
  • The addition of bempedoic acid to PCSK9i therapy was well-tolerated and had a safety profile comparable to that observed in patient with placebo and a PCSK9i.


2 Months of bempedoic acid treatment added to a PCSK9i therapy in patients with hypercholesterolemia reduced LDL-c levels further compared to those with a PCSK9i and placebo. The addition of bempedoic acid was safe and well-tolerated.


1. Klimchak AC, Patel MY, Iorga S¸R, et al. Lipid treatment and goal attainment characteristics among persons with atherosclerotic cardiovascular disease in the United States. Am J Prevent Cardiol. 2020;1. doi:10.1016/j.ajpc.2020.100010.

2. Ray KK, Molemans B, Schoonen WM, et al. EU-wide cross-sectional observational study of lipid-modifying therapy use in secondary and primary care: the DA VINCI study. Eur J Prev Cardiol. 2020. August 28, 2020. Aug 28;zwaa047.

3. Cannon CP, de Lemos JA, Rosenson RS, et al. Getting to an ImprOved understanding of low-density lipoprotein-cholesterol and dyslipidemia management (GOULD): methods and baseline data of a registry of high cardiovascular risk patients in the United States. Am Heart J. 2020;219:70–77.

4. Navar AM, Wang TY, Li S, et al. Lipid management in contemporary community practice: results from the Provider Assessment of Lipid 455 Management (PALM) Registry. Am Heart J. 2017;193:84–92.

5. Pinkosky SL, Newton RS, Day EA, et al. Liver-specific ATP-citrate lyase inhibition by bempedoic acid decreases LDL-C and attenuates atherosclerosis. Nat Commun. 2016;7:13457.

6. Ray KK, Bays HE, Catapano AL, et al. Safety and efficacy of bempedoic acid to reduce LDL cholesterol. N Engl J Med. 2019;380:1022–1032.

7. Thompson PD, MacDougall DE, Newton RS, et al. Treatment with ETC-1002 alone and in combination with ezetimibe lowers LDL cholesterol in hypercholesterolemic patients with or without statin intolerance. J Clin Lipidol. 2016;10:556–567.

Find this article online at J Clin Lipidol

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