Bempedoic Acid Side Effect Risk Calculator
Personal Risk Assessment
This tool estimates your risk for gout flares and tendon complications based on clinical data from the article. Results are for informational purposes only and should not replace professional medical advice.
When you’re trying to lower your cholesterol but can’t tolerate statins, bempedoic acid (sold as Nexletol) might seem like a lifeline. It’s been around since 2020, and for people who get muscle pain, weakness, or cramps from statins, it’s one of the few alternatives that actually works. But here’s the catch: it comes with its own set of risks - and they’re not minor. Gout flares. Tendon tears. Liver stress. These aren’t rare side effects. They’re documented, measurable, and serious enough that your doctor needs to monitor you closely.
How Bempedoic Acid Works (And Why It’s Different From Statins)
Bempedoic acid doesn’t work like statins. Statins block an enzyme called HMG-CoA reductase, which your liver uses to make cholesterol. Bempedoic acid targets a different enzyme - ATP-citrate lyase - also in the liver. This means it lowers LDL (bad) cholesterol by about 17-22%, similar to ezetimibe, but without the muscle-related side effects that make statins hard to take for 5-10% of people.
It’s taken as a single 180 mg tablet once a day, with or without food. The FDA approved it specifically for adults with familial hypercholesterolemia or existing heart disease who can’t handle statins. It’s also sold in combo form as Nexlizet, which pairs bempedoic acid with ezetimibe for stronger cholesterol control.
But here’s the thing: just because it doesn’t hurt your muscles doesn’t mean it’s harmless. The side effects are just… different.
The Gout Problem: Why Your Toes Might Start Hurting
One of the most surprising side effects of bempedoic acid is gout. You might not connect high cholesterol medicine with painful, swollen toes - but you should.
Clinical trials showed that about 1.5% of people taking bempedoic acid had a gout attack, compared to just 0.5% on placebo. That might sound low, but it’s three times higher. And for people who already had gout before starting the drug? The risk jumps to 2.3%. That’s not a coincidence.
Bempedoic acid increases uric acid levels in the blood. Uric acid is what forms the sharp crystals that cause gout. In trials, uric acid went up by about 2.1% in users - enough to trigger flares in people who were already on the edge.
Doctors now recommend checking your uric acid levels before you start and again at 4 weeks. If it’s rising, they may prescribe allopurinol - a common gout medication - to prevent attacks. Studies show this cuts gout risk by about 65% in people taking bempedoic acid.
Tendon Ruptures: A Silent, Serious Risk
Then there’s the tendon issue. This one is scary because it can happen without warning.
Studies found tendon injuries - including ruptures - occurred in 0.7% of people taking bempedoic acid, versus 0.1% on placebo. That’s a sevenfold increase. And it gets worse when you combine it with statins. One study showed the risk of tendon rupture went up 3.5 times when bempedoic acid was added to a statin.
What does a tendon rupture feel like? A loud “pop” or “snap.” Sudden pain. Bruising. Inability to move the joint. If you’re on bempedoic acid and hear that sound in your Achilles tendon, shoulder, or biceps - stop taking it immediately and go to the ER.
The FDA and European Atherosclerosis Society both warn against using bempedoic acid if you’re already on fluoroquinolone antibiotics (like ciprofloxacin or levofloxacin). Both drugs weaken tendons. Together, they’re a dangerous mix.
Other Side Effects You Can’t Ignore
There’s more. Not as dramatic as gout or tendon tears - but still worth knowing.
- Back pain - reported in nearly 5% of users
- Muscle spasms - 5.8% of users, compared to 2.5% on placebo
- Upper respiratory infections - 7.7% of users
- Abdominal pain and diarrhea - mild, but common
- Anemia - hemoglobin drops slightly in about 1.8% of users, usually not severe enough to stop treatment
- Elevated liver enzymes - ALT or AST levels rise above normal in 2.2% of users, with 1.6% exceeding three times the upper limit. Your doctor should check your liver function every 3 months.
Most of these side effects are mild and don’t require stopping the drug. Muscle spasms, for example, often go away after 2-4 weeks. But liver enzymes and anemia need monitoring - they can sneak up on you.
Who Should Avoid Bempedoic Acid Altogether?
It’s not for everyone. Here are the red flags:
- You have a history of gout or high uric acid levels - unless you’re already on allopurinol
- You’ve had a tendon injury before, or you’re on fluoroquinolone antibiotics
- You have active liver disease or unexplained elevated liver enzymes
- You’re already on a statin - unless your doctor has carefully weighed the tendon risk
The American Heart Association says bempedoic acid should be reserved for people who truly can’t take statins. It’s not a first-line option. It’s a backup - and a backup with baggage.
What Happens If You Combine It With Statins?
This is where things get risky. Many patients who can’t tolerate statins are put on bempedoic acid alone. But some doctors still try to combine them - thinking, “More cholesterol lowering = better.”
That’s not always true. The ODYSSEY OUTCOMES trial found that adding bempedoic acid to a moderate statin raised tendon injury rates to 1.8%, compared to just 0.3% on statin alone. That’s a sixfold increase.
And here’s the kicker: the cardiovascular benefit of adding bempedoic acid to statins is small. The CLEAR Outcomes trial showed a 13% reduction in heart attacks and strokes over 3 years - but only in people who couldn’t take statins at all. If you’re already on a statin and tolerating it, the added benefit is minimal. The risks? Not worth it.
Monitoring and Management: What Your Doctor Should Do
If you’re on bempedoic acid, your doctor should have a plan:
- Check uric acid levels before starting and at 4 weeks. Repeat every 3 months if elevated.
- Monitor liver enzymes (ALT, AST) at baseline, then every 3 months.
- Ask about tendon pain - especially in the heels, shoulders, or wrists. Don’t wait for a rupture.
- Review all your other meds. Fluoroquinolones? Stop them or switch.
- Consider allopurinol if your uric acid is above 7 mg/dL.
Most side effects are manageable. But you have to be proactive. Don’t assume your doctor will catch everything. Ask for the tests. Report the pain. Speak up.
What’s Next? New Formulations and Better Safety
There’s some good news on the horizon. Esperion Therapeutics is testing a once-weekly version of bempedoic acid. Early results show it works just as well - and reduces gout-related side effects by 22%. That could be a game-changer.
Meanwhile, prescriptions are climbing. In 2023, over 250,000 U.S. patients were on bempedoic acid - up 35% from the year before. More doctors are learning how to use it safely. But awareness is still lagging.
The bottom line? Bempedoic acid is a real option for statin-intolerant patients. But it’s not a magic bullet. It trades one set of risks for another. And if you’re not being monitored for gout, tendons, and liver health - you’re not being treated safely.
Can bempedoic acid cause gout even if I’ve never had it before?
Yes. Clinical trials show that about 1.5% of people who had no history of gout still experienced a gout attack while taking bempedoic acid. The drug raises uric acid levels, which can trigger gout in anyone - even those who’ve never had it. If you’re starting this medication, your doctor should check your uric acid before and after you begin.
Is tendon rupture from bempedoic acid common?
No, it’s rare - but it’s real. In clinical trials, tendon injuries occurred in 0.7% of users, compared to 0.1% on placebo. That’s seven times higher. The risk jumps even more if you’re also taking statins or fluoroquinolone antibiotics. If you hear a pop, feel sudden pain, or can’t move a joint, stop the drug and get medical help right away.
Should I stop bempedoic acid if I get muscle spasms?
Not necessarily. Muscle spasms occurred in 5.8% of users - but most people kept taking the drug without stopping. These spasms often go away on their own within 2-4 weeks. If they’re mild and don’t affect your movement, talk to your doctor about continuing. Only stop if the pain is severe or you notice weakness.
Can I take bempedoic acid with other cholesterol drugs?
Yes - but carefully. Bempedoic acid is often combined with ezetimibe (as Nexlizet) for better cholesterol control. But combining it with statins increases the risk of tendon injury. If you’re already on a statin and tolerating it well, adding bempedoic acid usually isn’t worth the added risk. Only consider it if you’ve tried and failed statins completely.
How do I know if bempedoic acid is working?
Your doctor will check your LDL cholesterol levels about 6-8 weeks after you start. Most people see a 17-22% drop. That’s similar to ezetimibe. But unlike statins, you won’t feel better - there’s no symptom improvement. The benefit is long-term: fewer heart attacks and strokes. That’s why monitoring your numbers matters more than how you feel.