From the Guidelines
For a patient with multivessel atherosclerosis already on a statin, adding Repatha (evolocumab) is recommended if LDL cholesterol levels remain above 70 mg/dL despite maximally tolerated statin therapy, as it can significantly lower LDL cholesterol and reduce the risk of cardiovascular events. According to the 2022 ACC expert consensus decision pathway on the role of nonstatin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk 1, Repatha is a reasonable addition to maximally tolerated statin therapy in patients with clinical ASCVD who are at very high risk and have an LDL-C level ≥70 mg/dL. The typical dose of Repatha is 140 mg subcutaneously every 2 weeks or 420 mg monthly.
Some key points to consider when adding Repatha to a patient's treatment regimen include:
- Baseline LDL levels should be checked before starting Repatha, and follow-up testing should occur within 4-8 weeks after initiation to assess response 1
- Repatha works by preventing the degradation of LDL receptors on liver cells, allowing more LDL cholesterol to be removed from the bloodstream
- Common side effects include injection site reactions, nasopharyngitis, and upper respiratory tract infections
- Insurance coverage can be challenging, so prior authorization is often required, and patients may need assistance programs if cost is prohibitive
It's also important to note that the 2018 AHA/ACC/multisociety cholesterol guideline recommends using an LDL-C threshold of 70 mg/dL to consider the addition of nonstatin therapy to maximally tolerated statin therapy in patients with ASCVD 1. Additionally, the 2018 guideline states that ezetimibe is recommended as the initial nonstatin therapy in patients with clinical ASCVD who are receiving maximally tolerated statin therapy and have an LDL-C level ≥70 mg/dL. However, in patients with clinical ASCVD who are judged to be at very high risk and are being considered for PCSK9 mAb therapy, maximally tolerated LDL-C–lowering therapy should include maximally tolerated statin therapy and ezetimibe 1.
From the Research
Patient with Multivessel Atherosclerosis on a Statin
Should they take Repatha as well?
- The use of evolocumab (Repatha) in patients with multivessel atherosclerosis on a statin has been studied in several clinical trials 2, 3, 4, 5, 6.
- Evolocumab has been shown to significantly reduce low-density lipoprotein cholesterol (LDL-C) levels in patients with primary hypercholesterolemia or mixed dyslipidemia, including those on statin therapy 2.
- The addition of evolocumab to statin therapy has been found to confer a significant reduction in major cardiovascular events, including a 20% reduction in the composite of cardiovascular death, myocardial infarction, or stroke 6.
- The efficacy of evolocumab in reducing LDL-C levels and preventing cardiovascular events has been maintained in the long term, with no apparent increase in adverse events apart from a small increase in local injection site reactions 6.
- Real-world evidence has also shown that evolocumab is effective in reducing LDL-C levels and preventing cardiovascular events in a variety of high- and very high-risk patients, including those with multivessel atherosclerosis 6.
- The use of evolocumab in combination with statin therapy may be considered for patients with multivessel atherosclerosis who do not achieve adequate LDL-C reduction with statin therapy alone 3, 5.