What to do if Praluent (alirocumab) causes weakness in an 87-year-old female patient?

Management of Praluent (Alirocumab)-Induced Weakness in an 87-Year-Old Female

For an 87-year-old female experiencing weakness with Praluent (alirocumab), discontinuation of the medication is recommended with consideration of alternative lipid-lowering therapies based on the patient's cardiovascular risk profile.

Assessment of Weakness and Initial Management

1. Evaluate the weakness:

   • Determine if weakness is generalized or localized
   • Assess timing in relation to Praluent injections
   • Rule out other causes (electrolyte abnormalities, anemia, hypothyroidism)

2. Initial management:

   • Discontinue Praluent immediately as weakness is a concerning adverse effect in an elderly patient
   • Monitor for improvement of symptoms after discontinuation
   • Report the adverse event to appropriate regulatory authorities

Alternative Treatment Options

First-line alternatives:

• Ezetimibe (10 mg daily) 1:
  • Modest but effective LDL reduction (18-24%)
  • Well-tolerated with minimal side effects
  • Particularly suitable for elderly patients with statin intolerance
  • Oral administration (once daily)

Second-line alternatives (if ezetimibe insufficient):

• Bempedoic acid 2:

  • Oral administration
  • Demonstrated cardiovascular outcome benefits in statin-intolerant patients
  • 15-24% LDL-C reduction
  • Monitor for risk of gout and tendon rupture in elderly patients 3

• Inclisiran 1, 2:

  • Less frequent dosing (initial doses at day 1 and day 90, then every 6 months)
  • ~50% LDL-C reduction
  • May be better tolerated than PCSK9 monoclonal antibodies in some patients
  • Administered by healthcare professionals, ensuring proper administration

Special Considerations for Elderly Patients

1. Polypharmacy concerns:

   • Evaluate all current medications for potential interactions
   • PCSK9 inhibitors and inclisiran have minimal drug-drug interactions, which may be advantageous in elderly patients on multiple medications 3

2. Frailty assessment:

   • Frailty status should be evaluated as it predicts adverse outcomes and can help guide therapy decisions 3
   • Consider functional status and life expectancy when determining aggressiveness of lipid management

3. Risk-benefit analysis:

   • Weigh cardiovascular risk reduction benefits against quality of life impacts
   • In very elderly patients (≥85 years), data on PCSK9 inhibitors are limited 3

Monitoring After Medication Change

1. Follow-up schedule:

   • Reassess symptoms within 2-4 weeks after discontinuing Praluent
   • Check lipid panel 4-12 weeks after initiating alternative therapy
   • Monitor for any new adverse effects with alternative therapy

2. LDL-C targets:

   • Adjust targets based on patient's overall cardiovascular risk profile
   • For very high-risk patients: <55 mg/dL + ≥50% reduction 2
   • For high-risk patients: <70 mg/dL + ≥50% reduction 2
   • For moderate-risk patients: <100 mg/dL 2

Common Pitfalls and Caveats

• Don't immediately restart another PCSK9 inhibitor (evolocumab) as cross-reactivity may occur
• Don't undertreat lipids in elderly patients solely based on age; cardiovascular risk reduction remains important
• Don't overlook non-pharmacological approaches (Mediterranean diet, physical activity as tolerated)
• Avoid high-intensity statins in this age group if the patient has previously experienced adverse effects

By following this approach, you can effectively manage Praluent-induced weakness while maintaining appropriate lipid management for this elderly patient.