Bempedoic Acid Side Effects: Gout, Tendon Risks, and What You Need to Know

When you can’t take statins because of muscle pain or weakness, bempedoic acid (sold as Nexletol) looks like a lifeline. It lowers LDL cholesterol without hitting your muscles the same way statins do. But here’s the catch: it doesn’t come without its own set of risks. If you’re considering this drug, you need to know about the real dangers - especially gout and tendon injuries - before you start taking it.

How Bempedoic Acid Works (And Why It’s Different From Statins)

Bempedoic acid works in the liver to block a different step in cholesterol production than statins. While statins inhibit HMG-CoA reductase, bempedoic acid targets ATP-citrate lyase. This means it doesn’t enter muscle tissue the same way, which is why muscle pain is far less common. For people who’ve had to quit statins because of cramps, weakness, or rhabdomyolysis, this is a big deal.

It’s not a miracle drug, though. It lowers LDL by about 17-22%, which is solid but not as strong as high-dose statins. That’s why it’s usually prescribed for people who can’t tolerate statins or need extra help lowering cholesterol even after taking them. It’s also sold as Nexlizet - a combo pill with ezetimibe - for patients needing more aggressive treatment.

The Most Common Side Effects You’ll Actually Feel

Most people tolerate bempedoic acid okay, but side effects are real and noticeable. In clinical trials, about 1 in 20 people reported:

• Muscle spasms (5.8%)
• Back pain (4.9%)
• Pain in hands or feet (3.4%)
• Upper respiratory infections (7.7%)
• Bronchitis (3.5%)

These aren’t rare. If you start taking it and suddenly feel like you’re always catching colds, or your lower back aches more than usual, it could be the drug. Most of these symptoms fade after a few weeks, but if they don’t, talk to your doctor. About 1.2% of people stopped taking it because of discomfort - not because it was dangerous, but because it made daily life harder.

Gout: The Hidden Risk Nobody Talks About

This is where things get serious. Bempedoic acid raises uric acid levels in your blood - by about 2.1% compared to placebo. That might sound small, but it’s enough to trigger gout attacks in people who never had them before.

In trials, 1.5% of people taking bempedoic acid had a gout flare. That’s three times higher than placebo. For those who already had gout, the risk jumped to 2.3%. If you’ve ever had a swollen, red, burning big toe - especially at night - you know how painful this is. And it can happen fast: most gout flares started within the first four weeks of treatment.

Doctors now recommend checking your uric acid levels before starting bempedoic acid and again at four weeks. If your levels are high, you may be put on allopurinol - a cheap, old drug that prevents gout. Studies show this cuts gout risk by 65%. If you’ve had gout before, this isn’t optional. Skip it, and you’re gambling with intense pain and possible joint damage.

Tendon Rupture: A Silent, Serious Danger

Here’s the side effect that scares cardiologists the most: tendon injuries. In clinical trials, 0.7% of people on bempedoic acid had tendon problems - including ruptures. That’s seven times higher than placebo. And it’s not just about the Achilles tendon. Shoulder, biceps, and rotator cuff tendons are also at risk.

What makes this dangerous is how sudden it is. People report hearing a “snap” or “pop,” then immediate pain and swelling. Some can’t walk. Others can’t lift their arm. It doesn’t always happen during exercise - sometimes it just happens while walking or standing.

The risk skyrockets if you’re taking bempedoic acid with a statin. One study found tendon rupture risk was 3.5 times higher when both drugs were used together. That’s why the European Atherosclerosis Society says: don’t use bempedoic acid if you’re already on fluoroquinolone antibiotics (like ciprofloxacin), have a history of tendon tears, or are older than 60. Those are red flags.

What About Liver and Blood Issues?

Some people get mild liver enzyme elevations - ALT or AST levels above normal. That happened in 2.2% of users, compared to 0.9% on placebo. In 1.6% of cases, levels went above three times the upper limit. Your doctor should check your liver function at the start and again after 4-8 weeks. If it keeps rising, they’ll likely stop the drug.

Anemia is another lesser-known side effect. Hemoglobin levels dropped slightly in about 1.8% of patients. But here’s the good news: most of these drops were mild - under 1 g/dL - and didn’t require stopping the medication. Still, if you’re feeling unusually tired, dizzy, or short of breath, get your blood checked.

Who Should Avoid Bempedoic Acid Altogether?

It’s not for everyone. Avoid it if:

• You’ve had a tendon rupture before
• You’re taking fluoroquinolone antibiotics (cipro, levaquin, etc.)
• You have active gout or very high uric acid levels (unless you’re on allopurinol)
• You have severe liver disease
• You’re pregnant or breastfeeding

The American Heart Association says this drug should only be used for people who truly can’t take statins. If you’ve tried two or three statins and had muscle pain every time, then yes - this might be your best option. But if you just didn’t like the idea of taking a daily pill, or you had mild muscle soreness that went away after a week, you might not need it.

What to Do If You’re Already Taking It

If you’re on bempedoic acid right now, here’s your action plan:

1. Check your uric acid level - if you haven’t had it tested since you started, ask your doctor for a blood test.
2. Watch for sudden joint pain, especially in your big toe. If it swells and turns red, stop the drug and call your doctor.
3. Pay attention to any tendon pain, especially in heels, shoulders, or wrists. If you hear a pop or can’t move a joint normally, go to urgent care immediately.
4. Don’t take fluoroquinolone antibiotics while on this drug. If you need an antibiotic, tell your provider you’re on Nexletol.
5. Keep your liver function tests on schedule. Most doctors check at 4 weeks and then every 3 months.

Most people who take bempedoic acid do fine. But the side effects aren’t theoretical. They happen. And they can change your life in seconds - like a ruptured tendon or a gout attack that leaves you bedridden for days.

Is It Worth It?

The CLEAR Outcomes trial showed bempedoic acid reduces heart attacks, strokes, and heart-related deaths by 13% in high-risk patients. That’s meaningful. For someone with a history of heart disease who can’t take statins, that benefit might outweigh the risks.

But if you’re just borderline high cholesterol and your doctor is pushing it because “it’s new,” think again. You don’t need it. Lifestyle changes - diet, walking, weight loss - still work better than most pills for mild cases. And if you can tolerate even a low-dose statin, stick with it. Statins have 40 years of safety data. Bempedoic acid has five.

Bottom line: bempedoic acid is a tool - not a first-line fix. Use it only when necessary, monitor closely, and don’t ignore the warning signs. Your tendons and joints will thank you.