No, You Should Not Use Repatha and Praluent at the Same Time
Do not combine Repatha (evolocumab) and Praluent (alirocumab) simultaneously—these are both PCSK9 inhibitors with the same mechanism of action, and using them together provides no additional benefit while potentially increasing costs and injection burden without improving outcomes.
Why This Combination Makes No Sense
Both medications work through an identical mechanism: they are monoclonal antibodies that bind to PCSK9 enzyme, preventing degradation of LDL receptors and thereby lowering LDL cholesterol 1. Using both simultaneously would be:
- Pharmacologically redundant: They target the exact same pathway
- Clinically unjustified: No evidence supports additive benefit
- Financially wasteful: Both are expensive medications ($5,000-14,000 annually)
- Unnecessarily burdensome: Doubles injection frequency without benefit
What the Guidelines Say
The 2022 ACC Expert Consensus clearly describes both agents as alternatives within the same drug class 1. The FDA-approved indications for both drugs are essentially identical:
- Alirocumab: Reduces LDL-C by 45-58% when added to maximally tolerated statin therapy 1
- Evolocumab: Reduces LDL-C by 58-64% when added to maximally tolerated statin therapy 1
Neither drug label mentions or suggests combination therapy with another PCSK9 inhibitor 2, 3.
Choosing Between Them (Not Combining)
If you need to select one PCSK9 inhibitor, consider:
Choose Alirocumab if:
- Primary concern is preventing hospitalization for unstable angina (42% reduction) 4
- Stroke prevention is the priority 4
Choose Evolocumab if:
- Coronary revascularization prevention is the goal 4, 5
- Patient has latex sensitivity (latex-free formulations available) 3
Either drug is appropriate for:
What to Do If LDL Goals Aren't Met
If a patient on one PCSK9 inhibitor hasn't reached LDL-C targets, the correct approach is:
- Optimize the current PCSK9 inhibitor dose (e.g., increase alirocumab from 75mg to 150mg every 2 weeks) 1
- Add complementary agents with different mechanisms:
- Switch from one PCSK9 inhibitor to the other if there are tolerability issues or insurance coverage problems 6
Common Pitfall to Avoid
The most common error is thinking "more is better" when LDL targets aren't met. Doubling up on PCSK9 inhibitors saturates the same pathway without additional benefit. Studies show that switching between alirocumab and evolocumab produces equivalent LDL-C lowering without significant differences in clinical outcomes 6, 7.
Bottom Line
Select one PCSK9 inhibitor based on patient-specific factors (insurance coverage, injection preference, specific cardiovascular risk profile). If inadequate response, optimize dosing or add agents with different mechanisms—never combine two PCSK9 inhibitors 1, 6.