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) might be your next option. It lowers LDL cholesterol by blocking a different step in cholesterol production than statins do. But it’s not without risks. While it avoids the muscle problems that make statins hard to tolerate, it brings its own set of concerns - especially gout and tendon injuries. If you're considering this drug, you need to know what’s really happening in your body when you take it.

How Bempedoic Acid Works - and Why It’s Different

Bempedoic acid works in the liver to stop cholesterol from being made. It targets an enzyme called ATP-citrate lyase, which is earlier in the cholesterol-making chain than where statins act. That’s why it doesn’t cause the same muscle side effects. Statins interfere with a pathway that muscles also rely on, which is why up to 15% of people can’t take them. Bempedoic acid skips that problem entirely.

But here’s the catch: even though it avoids muscle pain, it doesn’t avoid all side effects. In fact, some of the risks it introduces are serious - and often overlooked. The FDA approved it in 2020 for people with inherited high cholesterol or those who already have heart disease. It’s not a first-line drug. It’s meant for when statins fail.

Gout: The Most Common Surprising Side Effect

One of the biggest surprises with bempedoic acid is how often it triggers gout. In clinical trials, about 1.5% of people taking it had a gout attack - compared to just 0.5% on placebo. That’s a threefold increase. For people who already had gout before starting the drug, the risk jumps to 2.3%.

Why does this happen? Bempedoic acid raises uric acid levels in the blood. Uric acid is a waste product that, when too high, forms sharp crystals in joints - especially the big toe. That’s gout. Symptoms come on fast: redness, swelling, burning pain so intense you can’t even tolerate a bedsheet on your foot.

Most cases happen within the first four weeks of starting the medication. That’s why doctors are now told to check your uric acid levels before you begin and again at four weeks. If your levels are climbing, they might prescribe allopurinol - a cheap, well-known drug that lowers uric acid. Studies show this cuts gout risk by about 65% in people taking bempedoic acid.

Tendon Rupture: A Rare but Devastating Risk

Another serious side effect you won’t hear much about is tendon injury. In trials, 0.7% of people on bempedoic acid had tendon problems - compared to 0.1% on placebo. That sounds small, but when it happens, it’s life-changing.

Tendon rupture means the cord connecting muscle to bone tears. It often happens in the Achilles tendon (back of the ankle), but can also occur in the shoulder, hand, or rotator cuff. People describe hearing a loud “pop,” followed by sudden pain and inability to stand on tiptoe or lift their arm.

The risk goes up dramatically if you’re also taking a statin. One study found that people on both drugs had a 3.5 times higher chance of tendon rupture than those on placebo alone. The FDA warns that this combination should be avoided unless absolutely necessary. If you’re on both, your doctor should be monitoring you closely.

Fluoroquinolone antibiotics - like ciprofloxacin or levofloxacin - also increase tendon risk. If you’re prescribed one of these while taking bempedoic acid, tell your doctor immediately. The European Atherosclerosis Society says people with prior tendon problems or those on fluoroquinolones should avoid bempedoic acid altogether.

Other Side Effects You Might Experience

Not everything is dramatic. Many side effects are mild and go away on their own:

• Back pain (4.9% of users)
• Muscle spasms (5.8%) - often fades after a few weeks
• Pain in hands or feet (3.4%)
• Upper respiratory infections (7.7%) - think colds and bronchitis
• Stomach pain or diarrhea (2.8%)
• Fatigue or flu-like symptoms

Some people develop mild anemia - hemoglobin drops by less than 1 g/dL on average. This rarely causes symptoms and doesn’t usually require stopping the drug.

Liver enzymes (ALT and AST) rise in about 2.2% of users. That’s not liver damage - it’s just a signal your liver is working harder. But if levels go above three times the normal limit, your doctor will likely stop the medication.

Who Should Avoid Bempedoic Acid?

This drug isn’t for everyone. Avoid it if:

• You’ve had a previous tendon rupture or chronic tendonitis
• You’re currently taking fluoroquinolone antibiotics
• You have untreated high uric acid or a history of frequent gout attacks
• You have severe liver disease

Also, if you’re pregnant, breastfeeding, or planning to become pregnant, talk to your doctor. There’s not enough data to say it’s safe.

What to Do If You’re Already Taking It

If you’re on bempedoic acid, here’s what to watch for:

1. Check your uric acid levels at 4 weeks and every 3 months after that.
2. Report any sudden joint pain - especially in your big toe - right away.
3. Be alert for tendon pain, swelling, or a “pop” sound during movement.
4. Don’t start any new antibiotics without telling your doctor you’re on this drug.
5. Keep moving, but avoid sudden intense exercise. Gradual activity helps tendon health.

Most side effects are manageable. Muscle spasms often fade after 2-4 weeks. Only 1.2% of people quit the drug because of them. Gout and tendon risks are real, but preventable with the right monitoring.

How It Compares to Other Cholesterol Drugs

Compared to statins, bempedoic acid is much gentler on muscles - only 5.8% report muscle issues versus 10-15% with statins. But it’s worse for gout and tendons.

Compared to ezetimibe (another non-statin option), bempedoic acid lowers LDL about the same amount - around 17-22%. But it causes more gout (1.5% vs. 0.7%) and more tendon injuries (0.7% vs. 0.2%).

When added to a statin, bempedoic acid boosts LDL reduction even more - but tendon risk jumps to 1.8%. That’s why most doctors only combine them if LDL is still dangerously high despite maximum statin doses.

The CLEAR Outcomes trial showed that bempedoic acid reduces heart attacks, strokes, and heart-related deaths by 13%. That’s a big win. But it only applies to people with existing heart disease. For them, the benefits often outweigh the risks.

What’s Next for This Drug?

Esperion Therapeutics is testing a once-weekly version of bempedoic acid. Early results show it works just as well - and cuts gout-related side effects by 22%. That could change how this drug is used.

Prescriptions in the U.S. have grown 35% year over year. More doctors are learning how to use it safely. But the American Heart Association still says: reserve it for people who truly can’t take statins.

It’s not a magic bullet. It’s a tool - useful, but with clear limits. If you’re considering it, make sure you understand the trade-offs. Lower cholesterol? Yes. But you’re trading one risk for another.