Bempedoic Acid to Improve LDL-C Levels in Patients With Statin Intolerance

Jun 25, 2025   |  Emily Littman, MD; Erin D. Michos, MD, FACC
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A 62-year-old man with a medical history of obesity, hyperlipidemia, osteoarthritis, gout, and type 2 diabetes mellitus (DM) presents to his primary care provider (PCP) for a routine health visit.

He is currently taking naproxen 250 mg twice daily, ezetimibe 10 mg, and metformin 1000 mg twice daily for his medications. Three years ago, he was started on atorvastatin 20 mg daily to treat his high cholesterol levels but discontinued it after 2 months due to persistent muscle cramps, which resolved shortly after stopping the medication. He then tried rosuvastatin 5 mg daily but experienced similar symptoms, so this was discontinued. He expresses reluctance to try another statin and would like to avoid any injectable medications. He is open to nonstatin oral options to help lower his cholesterol levels without the adverse effects of muscle cramping.

He works as an accountant and follows a mostly sedentary lifestyle. He has recently started a low-sodium diet. He has a family history of coronary artery disease (CAD). His brother recently had a myocardial infarction (MI) at 53 years of age. He does not smoke, drink alcohol, or use any substances. He does not have any allergies.

On examination, his body mass index is 33.8, blood pressure is 134/78 mm Hg, heart rate is 75 bpm, and temperature is 36.2° C. His cardiopulmonary and musculoskeletal examination findings are unremarkable.

Laboratory evaluation includes a comprehensive metabolic panel (CMP) with significant findings of creatinine (Cr) level 1.2 mg/dL, blood urea nitrogen level 18 mg/dL, hemoglobin level 13.2 g/dL, aspartate transaminase level 16 U/L, alanine transaminase level 14 U/L, fasting glucose level 145 mg/dL, hemoglobin A1c concentration 6.8%, and uric acid level 5 mg/dL. Lipid panel values include total cholesterol level 190 mg/dL, low-density lipoprotein cholesterol (LDL-C) level 122 mg/dL, high-density lipoprotein cholesterol level 38 mg/dL, triglyceride level 152 mg/dL, and lipoprotein(a) level 54 nmol/L.

The patient and his PCP discuss the risks and benefits of additional lipid-lowering therapy and, through shared decision-making, decide to start bempedoic acid.

Which one of the following features would make bempedoic acid a less favorable treatment option?

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