What are the considerations for using Repatha (evolocumab) in patients with a history of tendinitis?

Repatha (Evolocumab) and Tendinitis: Clinical Considerations

Repatha (evolocumab) can be safely used in patients with a history of tendinitis as it has no known association with tendon disorders, unlike bempedoic acid which carries warnings about tendon rupture. 1

Safety Profile of Repatha in Relation to Tendinitis

Repatha is a PCSK9 inhibitor that works by blocking PCSK9 to reduce LDL cholesterol levels. According to the 2022 ACC expert consensus:

• The main adverse effects of evolocumab include nasopharyngitis, upper respiratory tract infection, influenza, back pain, and injection site reactions 1
• No warnings or precautions specifically related to tendinitis or tendon disorders are listed for Repatha 1, 2
• The contraindication for Repatha is limited to history of hypersensitivity to the medication 1

In contrast, bempedoic acid (another lipid-lowering medication) carries specific warnings about tendon disorders:

• Bempedoic acid should be discontinued immediately if tendon rupture occurs 1
• Patients with a history of tendon disorders or tendon rupture should consider alternative therapy to bempedoic acid 1

Efficacy and Long-Term Safety of Repatha

Repatha has demonstrated significant efficacy in reducing cardiovascular events:

• In the FOURIER trial, evolocumab reduced the primary endpoint of CV death, MI, stroke, revascularization, or hospitalization for unstable angina 1, 3
• Long-term safety data from the OSLER-1 trial showed consistently excellent LDL-C-lowering efficacy and safety over 5 years 4
• Yearly serious adverse event rates during evolocumab treatment ranged from 6.9% to 7.9%, comparable to standard of care 4

Clinical Decision Algorithm for Patients with Tendinitis History

1. Assess cardiovascular risk and LDL-C levels

   • Determine if patient meets criteria for PCSK9 inhibitor therapy (established ASCVD, FH, or high-risk features with inadequate LDL-C control on statins) 2

2. Review medication history

   • If patient is on bempedoic acid and has history of tendinitis, consider switching to Repatha 1
   • If patient is on fluoroquinolones (e.g., moxifloxacin), be aware of their association with tendinitis 1

3. Evaluate Repatha as an option

   • Repatha has no known association with tendon disorders 1, 2
   • Standard dosing: 140 mg every 2 weeks or 420 mg monthly subcutaneously 2

4. Monitor for adverse effects

   • Focus on common side effects: injection site reactions, nasopharyngitis, upper respiratory infections 1, 2
   • No specific monitoring for tendon-related issues is required with Repatha 1, 2

Important Considerations and Caveats

• Medication interactions: Unlike tendinitis concerns, be aware that needle covers on Repatha products contain latex, which is relevant for latex-sensitive patients 1

• Cost and access: Prior authorization processes for Repatha may be burdensome, and the high cost may restrict its use despite excellent efficacy 2

• Efficacy monitoring: LDL-C can be measured as early as 4 weeks after initiation of Repatha therapy 2

• Fluoroquinolone comparison: Unlike Repatha, fluoroquinolones like moxifloxacin carry explicit warnings about tendon inflammation and rupture, particularly in patients over 60 years or those using corticosteroids 1

In summary, for patients with a history of tendinitis requiring lipid-lowering therapy, Repatha represents a safe option with no known association with tendon disorders, unlike some other medications such as bempedoic acid or fluoroquinolones.