Repatha (evolocumab) alternatives: What can I take instead of Repatha?

Compare Repatha alternatives | ANGPTL3 | Bile acid sequestrants | Nexletol | Statins | Zetia | Natural alternatives | How to switch meds

High cholesterol levels are common in Americans. Almost 90 million American adults have high cholesterol. This is a total cholesterol level in your blood of 200 mg/ DL or higher. High cholesterol is a cause of strokes, heart attacks, and other cardiac disorders. 

Repatha (evolocumab) is an injectable treatment for lowering low-density lipoprotein cholesterol (LDL-C). LDL-C is known as the “bad” cholesterol, and we want that number to be as low as possible. Repatha is an antilipemic monoclonal antibody targeting PCSK9 and can be used in both primary and heterozygous familial hypercholesterolemia in adults and heterozygous familial hypercholesterolemia in children and adolescents. This drug binds to the LDL receptor site and promotes LDL breakdown by the liver. It is approved by the U.S. Food and Drug Administration (FDA) as an adjunct therapy when other first-line treatments cannot adequately lower LDL alone. A low-cholesterol diet should always be a part of the treatment plan. Repatha may also be used alone in patients who are at high risk for or have confirmed cardiovascular disease to lower the risk of heart disease, myocardial infarction (heart attack), stroke, and coronary revascularization. 

Not everyone will be a candidate for Repatha treatment. Those with a hypersensitivity to the ingredients in Repatha are not candidates for treatment. Latex is a component of the pre-filled syringe and autoinjector, so a patient allergic to latex could have a hypersensitive reaction. Repatha does have side effects that can be bothersome. These include injection site reactions, flu-like symptoms, upper respiratory tract infections, and headaches. There is not enough safety data to safely recommend Repatha use in pregnancy or while breastfeeding. The cost of Repatha may be prohibitive for some. At the time of publishing, the current retail price for a one-month supply of Repatha was over $700. Even with insurance, the cost burden of Repatha may be very high for some. Lastly, Repatha is an injectable drug. Some patients may have an aversion to this type of drug administration, which will make compliance more difficult. There are other options for lowering LDL cholesterol and reducing your cardiovascular risk if you don’t think Repatha is right for you.

What can I take in place of Repatha?

There are a variety of other drug types that can help lower LDL cholesterol levels and reduce cardiovascular risk. These range from over-the-counter and prescription nicotinic acid derivatives like niacin to prescription oral drugs and other injectables. Some of the oral options include bile acid sequestrants, fibric acid derivatives (fibrates), omega-3 agents, sterol transporter inhibitors, adenosine triphosphate-citrate lyase (ACL) inhibitors, and HMG-CoA reductase inhibitors, which are better known as statins. 

Suppose injectable treatments are appealing to the patient. In that case, alternatives to Repatha include angiopoietin-like protein 3 inhibitors (ANGPTL3), apolipoprotein B (Apo B) synthesis inhibitors, or other options in the antilipemic monoclonal antibody drug class (PCSK9 targeting).

Each alternative option has unique dosing, efficacy, side effect profiles, routes of administration, and cost factors to consider. Other medical conditions present for the patient may also play a role in drug selection. This is not to be interpreted as medical advice but is intended to present options to discuss with your prescriber.

Other alternatives to Repatha

• Questran (cholestyramine)
• Lopid (gemfibrozil)
• Trilipix  (fenofibric acid)
• Fenoglide (fenofibrate)
• Vascepa (icosapent ethyl)
• Vytorin (ezetimibe/ simvastatin)
• Mevacor (lovastatin)
• Livalo (pitavastatin)
• Lescol (fluvastatin)

RELATED: What’s the safest cholesterol medication?

Top 5 Repatha alternatives

The following are some of the most common alternatives to Repatha. Remember, all cholesterol-lowering therapies should be adjunct to lifestyle changes and a healthy diet.

1. Angiopoietin-like protein 3 inhibitors (ANGPTL3)

Evkeeza (evinacumab) is a recombinant human monoclonal antibody approved in children and adults as an adjunct to other therapies in familial hypercholesterolemia. Evkeeza inhibits lipoprotein lipase and endothelial lipase, which regulate lipid metabolism. This results in a reduction of LDL-C and triglycerides. This product, like Repatha, is an injection and is only given once monthly. The most common side effects are flu-like symptoms, dizziness, and runny nose. Evkeeza does not currently have a generic on the market. Evkeeza can only be administered in your provider’s office and be billed by them. This can not be purchased directly at the pharmacy for self-administration.

2. Bile acid sequestrants

Bile acid sequestrants are oral, non-adsorbed polymers with a high capacity to bind bile acids. This blocks the absorption of bile acids, and as this happens, the cholesterol 8-alpha-hydroxylase is upregulated. This leads to the conversion of cholesterol to bile acids, which are being blocked from absorption. This drug class effectively lowers LDL-C by up to 18% and total cholesterol by 10%. Drugs in this class are available in a powder for mixing with liquid to consume, as well as tablets. The tablets are large and hard to swallow for some, and the powder formulations may not be palatable for everyone. These drugs can lead to diarrhea, nausea, and dyspepsia. This class has generic options, which may make this more affordable than Repatha and some other options. This drug also has benefits for Type 2 diabetes and may be something to consider if this diagnosis is also present.

Examples: Welchol (colesevelam), Colestid (colestipol), Questran (cholestyramine)

3. Adenosine triphosphate-citrate lyase (ACL) inhibitor

Nexletol (bempedoic acid) is an ACL inhibitor that lowers LDL-C by inhibiting cholesterol synthesis in the liver. Nexletol is an oral tablet taken once daily and is only approved for use in adults. Nexletol is intended to be an adjunct to statin therapy. Nexletol was found in clinical trials to decrease the LDL-C level by up to 18% compared to placebo when combined with a statin. Nexletol can lead to hyperuricemia (uric acid in the blood) and increased liver enzyme levels. Muscle spasms and back pain can also occur when taking Nexletol. There is no generic for Nexletol, and the average retail price is over $500 per month without insurance.

4. Statin medications

Statin drugs have become a mainstay in primary hyperlipidemia treatment. For many, a statin alone may be enough to bring cholesterol levels to an acceptable range through mild to moderate intensity dosing. High-intensity statin dosing is necessary for some, but that comes with an increased risk for adverse events. Statins may be used alone or in combination with many other treatments listed here, including Repatha, to treat high cholesterol and prevent cardiovascular events. Statins work by inhibiting HMGCoA reductase and reducing cholesterol levels in liver cells. They are an oral, once-daily treatment with many generic forms available in the class. Statins are known for causing myalgias, or muscle pain, in the periphery. For some, these can be so bad that patients are unable to take statins.

Examples: Lipitor (atorvastatin), Crestor (rosuvastatin), Zocor (simvastatin)

5. Sterol transporter inhibitors

Zetia (ezetimibe)  is a sterol transporter inhibitor that can be combined with statins to lower LDL-C. Zetia is an oral, once-daily drug. There are combination versions of ezetimibe and a statin drug available to reduce the pill burden for patients who need both. Zetia works by inhibiting the adsorption of cholesterol in the small intestine. Those with liver disease should not use it. The most common side effects of Zetia are upper respiratory infection, diarrhea, and arthralgia. Zetia can be very effective in lowering LDL-C by up to 18%. 

Natural alternatives to Repatha

A plan for a healthy, low-cholesterol diet will accompany all medication treatment options for cholesterol. This includes lean cuts of meat and avoiding processed meat like bologna. chicken, turkey, or fish are great options. Season fresh vegetables with fresh herbs instead of oily sauces. You should also choose low-fat or non-fat dairy options and increase your fiber intake. Good dietary choices will be essential to successfully lowering your cholesterol levels.

There are some natural products and supplements that could assist in lowering your cholesterol. 

• Red yeast rice products contain a substance called monacolin K, which is chemically identical to lovastatin. In the U.S., the FDA will not allow the sale of red yeast rice formulations that contain more than trace amounts. It is not well known if trace-amount products are highly effective, but there is evidence that monacolin K-containing formulations have a cholesterol-lowering effect. They also may cause some of the same side effects as statins, including myalgias.
• Psyllium has been shown to have LDL-lowering effects and atherosclerosis development delay. Psyllium and other coarse fiber products form a thick gel-type substance that traps bile acids in the gastrointestinal system. From there- it is flushed by the body and eliminated as waste. Psyllium can be a part of your daily dietary intake if you drink plenty of fluids. Psyllium without fluid can lead to constipation or intestinal blockage due to the semi-solid formation it can form.
• Other products that may help lower cholesterol include niacin, soy, flaxseed, garlic, green tea, and oat bran.

RELATED: 10 natural remedies for high cholesterol

How to switch to a Repatha alternative

There may be various reasons you are considering a change from Repatha. Whether it is due to cost, side effects, method of administration, or allergic sensitivities, there are other cholesterol-lowering medications for your health. The first step is to speak to your healthcare provider. Having your cholesterol checked regularly with blood draws and lab work is important. The results of those tests can help you and your doctor find an appropriate choice. Other comorbidities, such as diabetes or high blood pressure, may also affect your choice. Your pharmacist or insurance plan can provide more information on your formulary coverage and what options would be most cost-effective with your plan. If you don’t have insurance or want to ensure you are paying the best price, head to www.singlecare.com to find the best prices at pharmacies near you.