Prescribing Repatha (Evolocumab)
Repatha (evolocumab) should be prescribed at a dose of 140 mg subcutaneously every 2 weeks OR 420 mg subcutaneously once monthly, administered into the abdomen, thigh, or upper arm with injection site rotation. 1
Indications and Patient Selection
Repatha is indicated for:
- Adults with established cardiovascular disease to reduce cardiovascular events
- Adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia (HeFH)
- Adults and pediatric patients aged 10 years and older with homozygous familial hypercholesterolemia (HoFH)
Priority should be given to:
- Patients with established ASCVD and LDL-C ≥70 mg/dL despite maximally tolerated statin plus ezetimibe
- Patients with familial hypercholesterolemia
- Statin-intolerant patients with high cardiovascular risk 2
Dosing Protocol
Standard Dosing
- Adults with established CVD or primary hyperlipidemia: 140 mg every 2 weeks OR 420 mg once monthly subcutaneously 1
- Pediatric patients ≥10 years with HeFH: 140 mg every 2 weeks OR 420 mg once monthly subcutaneously 1
Special Populations
- HoFH patients: Initial dose of 420 mg once monthly, can be increased to 420 mg every 2 weeks if clinically meaningful response not achieved in 12 weeks 1
- Patients on lipid apheresis: May initiate with 420 mg every 2 weeks to coincide with apheresis schedule; administer after apheresis session 1
Administration Instructions
Allow Repatha to warm to room temperature:
- 30 minutes for prefilled autoinjectors or syringes
- 45 minutes for on-body infusor with prefilled cartridge 1
Visually inspect solution (should be clear to opalescent, colorless to pale yellow)
Administer subcutaneously into:
- Abdomen
- Thigh
- Upper arm
- Rotate injection sites for each administration 1
For 420 mg dose, options include:
- Using single-dose on-body infusor with prefilled cartridge (5-minute administration)
- Giving 3 consecutive 140 mg injections within 30 minutes using prefilled autoinjectors or syringes 1
Monitoring
- Assess LDL-C when clinically appropriate
- LDL-lowering effect can be measured as early as 4 weeks after initiation
- For patients on 420 mg monthly dosing, measure LDL-C just prior to the next scheduled dose 1
- No specific laboratory monitoring required beyond routine lipid profile assessment
- No requirement for liver function tests, renal function, or complete blood counts 2
Missed Doses
- If missed dose is within 7 days: Administer and resume original schedule
- If more than 7 days after missed dose:
- For every 2-week dosing: Wait until next scheduled dose
- For monthly dosing: Administer and start new schedule based on this date 1
Expected Outcomes and Side Effects
- Expect 50-65% reduction in LDL-C levels from baseline 2
- Common side effects:
- Rare but serious: Hypersensitivity reactions 1
Special Considerations
- For patients with latex sensitivity, some Repatha presentations contain dry natural rubber in the needle cover
- Consider prescribing latex-free presentations for these patients 2, 1
- Unlike statins, no monitoring for muscle-related side effects, liver function, or glucose levels is required 2
Efficacy Evidence
Repatha has demonstrated significant cardiovascular benefit in the FOURIER trial, with a 15% relative risk reduction in the composite endpoint of cardiovascular death, MI, stroke, hospitalization for unstable angina, or coronary revascularization (HR 0.85,95% CI 0.79-0.92) 3, 4. The combined endpoint of cardiovascular death, MI, or stroke was reduced by 20% (HR 0.80,95% CI 0.73-0.88) 3.
Clinical Pearls
- Prior authorization processes may be burdensome; plan accordingly
- Cost considerations may limit access despite excellent efficacy profile 2
- Repatha can be safely used in patients with a history of tendinitis, with no known association with tendon disorders 2
- When switching between dosing regimens, administer the first dose of the new regimen on the next scheduled date of the prior regimen 1