bempedoic acid/ezetimibe

General

Pronunciation:
bem-pe-doe-ik as-id/e-zet-i-mibe

Trade Name(s)

• Nexlizet

Ther. Class.
lipid-lowering agents
none assigned

Pharm. Class.
temporary class adenosine triphosphate-citrate lyase inhibitors
cholesterol absorption inhibitors

Indications

Heterozygous familial hypercholesterolemia or established atherosclerotic cardiovascular disease in patients who require additional lowering of low-density lipoprotein cholesterol (LDL-C) levels (as adjunct to diet and maximally tolerated statin therapy).

Action

Bempedoic acid– Inhibits adenosine triphosphate-citrate lyase, which inhibits cholesterol synthesis in the liver and subsequently lowers LDL-C.  Ezetimibe– Inhibits absorption of cholesterol in the small intestine.

Therapeutic Effect(s):

Reduction in LDL-C levels.

Pharmacokinetics

Bempedoic acid

Absorption: Unknown.

Distribution: Some distribution to extravascular tissues.

Metabolism and Excretion: Metabolized in liver to active metabolite (ESP15228); both parent drug and ESP15228 are also metabolized via glucuronidation to inactive metabolites. 70% excreted in urine and 30% excreted in feces primarily as metabolites (<5% excreted as unchanged drug in urine and feces).

Half-life: 21 hr.

Ezetimibe

Absorption: Following absorption, rapidly converted to ezetimibe-glucuronide, which is active. Bioavailability is variable.

Distribution: Unknown.

Metabolism and Excretion: Undergoes enterohepatic recycling, mostly eliminated in feces, minimal renal excretion.

Half-life: 22 hr.

TIME/ACTION PROFILE (plasma concentrations)

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity
• Moderate or severe hepatic impairment
• OB:   Pregnancy (may cause fetal harm)
• Lactation: Lactation.

Use Cautiously in:

• History of gout
• Concurrent use of corticosteroids or fluoroquinolones, renal failure, or previous tendon disorders (↑ risk of tendon rupture/injury)
• Severe renal impairment or end-stage renal disease
• Pedi:  Safety and effectiveness in children not established;
• Geri:   ↑ risk of tendon rupture/injury in patients >60 yr.

Adverse Reactions/Side Effects

CV: atrial fibrillation

Derm: rash

GI: abdominal pain, cholecystitis, cholelithiasis, ↑ liver enzymes, nausea, pancreatitis

GU: benign prostatic hyperplasia, ↑ blood urea nitrogen, ↑ serum creatinine

Hemat: anemia

Metabolic: hyperuricemia, gout

MS: back pain, ↑ creatine kinase, muscle spasm, tendon rupture/injury

Resp: upper respiratory tract infection

Misc: HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS AND ANGIOEDEMA)

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

• Concurrent therapy with  corticosteroids  or  fluoroquinolones may ↑ the risk of tendon rupture/injury associated with bempedoic acid.
• Bempedoic acid may ↑ levels of and risk of myopathy with  pravastatin  and simvastatin ; do not exceed 40 mg/day of pravastatin or 20 mg/day of simvastatin.
• Effects of ezetimibe may be ↓ by  cholestyramine  or other  bile acid sequestrants.
• Concurrent use of  fibrates  may ↑ levels and the risk of cholelithiasis associated with ezetimibe.
•  Cyclosporine  may ↑ ezetimibe levels.
• Ezetimibe may ↑ risk of rhabdomyolysis when used with  HMG CoA-reductase inhibitors.

Route/Dosage

PO (Adults): One tablet once daily.

Availability

Tablets: bempedoic acid 180 mg/ezetimibe 10 mg

Assessment

• Obtain a diet history, especially with regard to fat consumption.
• Monitor for signs and symptoms of hyperuricemia (gout) periodically during therapy. May occur within 4 wks of therapy. Initiate treatment with urate-lowering drugs as appropriate.
• Monitor for signs and symptoms of tendon rupture (joint pain, swelling, inflammation) periodically during therapy. May occur within days to months of starting therapy and more frequently in patients >60 years of age, taking corticosteroid or fluoroquinolones, with renal failure, and with previous tendon disorders. Consider discontinuing therapy if symptoms occur and discontinue therapy if tendon rupture occurs.
• Monitor for signs and symptoms of allergic reactions (anaphylaxis, angioedema, rash, urticaria) during therapy.

Lab Test Considerations:

Evaluate serum cholesterol levels before initiating, after 8–12 wk of therapy, and periodically thereafter.

• Monitor serum uric acid levels periodically if symptoms of hyperuricemia occur.
• May cause ↑ BUN and serum creatinine.
• May cause ↓ hemoglobin and leukocytes and ↑ platelet count.
• May cause ↑ AST, ALT, and creatine kinase.

Potential Diagnoses

• Noncompliance (Patient/Family/Teaching) 

Implementation

• PO 

  Administer once daily without regard to food. Swallow tablet whole; do not break, crush, or chew.

  • Administer bempedoic acid/ezetimibe either at least 2 hrs before or at least 4 hrs after bile acid sequestrants.

Patient/Family Teaching

• Instruct patient to take medication as directed. Advise patient to read  Patient Information  before starting and with each Rx refill in case of changes.
• Advise patient that this medication should be used in conjunction with diet restrictions (fat, cholesterol, carbohydrates, alcohol), exercise, and cessation of smoking.
• Advise patient to notify health care professional if signs and symptoms of hyperuricemia (severe foot pain especially in the toe joint, tender joints, warm joints, joint redness, swelling) occur.
• Advise patient to rest at the first sign of tendinitis (pain, swelling, tears, inflammation of tendons including arm, shoulder, back of the ankle) or tendon rupture (hear or feel a snap or pop in a tendon area, bruising right after an injury in a tendon area, unable to move affected area or put weight on affected area) and stop medication and contact health care professional if tendinitis or tendon rupture symptoms occur.
• Advise patient to notify health care professional immediately if signs and symptoms of allergic reactions (swelling of face, lips, mouth or tongue; trouble breathing; wheezing; skin rashes, redness, or swelling; severe itching; dizziness or fainting; fast heart beat or pounding in chest) occur.
• Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications.
• Rep:  Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breast feeding. Bempedoic acid/ezetimibe should be discontinued during pregnancy and lactation.

Evaluation/Desired Outcomes

Reduction in LDL-C levels. Evaluate in 8–12 wks.