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Repatha Offers Additional LDL-C Reduction in a Convenient Dosage Form

Michael R. Page, PharmD, RPh
Richard Mullvain, RPh, BCPS (AQC), CCCC, a cardiovascular clinical pharmacist and expert in cardiovascular care at the Essentia Health Heart & Vascular Center in Duluth, Minnesota, delivered a focused clinical review on the topic of the PCSK9 inhibitor Repatha (evolocumab), and its impact on low-density lipoprotein cholesterol (LDL-C).
The safety of Repatha has been studied in 2651 patients exposed to therapy across 8 placebo-controlled trials. Adverse reactions observed over a 52-week trial and seven 12-week trials included local injection site reactions, which occurred in 3.2% of patients receiving Repatha versus 3% of patients receiving placebo; allergic reactions, which occurred in 5.1% of patients receiving Repatha versus 4.7% of patients receiving placebo; and neurocognitive adverse events, which were reported at a rate of 0.2% or less among both Repatha-treated patients and placebo-treated patients.3
Other important safety considerations include the potential for very low LDL-C levels and musculoskeletal adverse reactions. LDL-C levels less than 25 mg/dL were achieved in 1988 patients who received treatment with Repatha. Although there were no adverse consequences in patients with very low LDL-C levels, the long-term effects of very low LDL-C levels remains unknown. Musculoskeletal adverse reactions occurred in 14.3% of patients receiving Repatha versus 12.8% of patients receiving placebo. The most common adverse reactions occurring at a higher incidence with Repatha treatment were limited to back pain, arthralgia, and myalgia. Notably, there is some potential for immunogenicity with Repatha, as with all other therapeutic protein medications.3
Dosages of Repatha include a 140-mg subcutaneous injection administered every 2 weeks, and a 420-mg subcutaneous injection administered every month. In clinical trials, these dosage regimens led to similar LDL-C reductions, without any need for titration. Also available is the Repatha Pushtronex system, which is a single-use on-body infusor with prefilled cartridges. This device securely adheres to the body for hands-free subcutaneous administration of a monthly treatment (430 mg/3.5 mL) over the course of 9 minutes. A single-use prefilled autoinjector, Repatha SureClick, delivers a 140 mg/mL dose subcutaneously over 15 seconds. The SureClick autoinjector may be more appropriate for patients who are comfortable self-administering therapy with a handheld device. Both treatment formulations may be stored at room temperature for up to 30 days before use.3
Repatha is indicated as an adjunct to diet and maximally tolerated statin therapy for treatment of adults with heterozygous familial hypercholesterolemia or clinical ASCVD who require additional lowering of LDL-C. Repatha is also indicated as an adjunct to diet and other LDL-lowering therapies (eg, statins, ezetimibe, LDL apheresis) for the treatment of patients with homozygous familial hypercholesterolemia who require additional lowering of LDL-C. The effect of Repatha on cardiovascular morbidity and mortality has not been determined. Repatha is contraindicated in patients with a history of a serious hypersensitivity reaction to Repatha.3
In patients with clinical ASCVD or familial hypercholesterolemia who require additional LDL-C reduction, Repatha is a treatment option that has demonstrated LDL-C–lowering efficacy. Repatha may be administered via a once monthly or twice monthly subcutaneous injection, with no dose titration needed.
1. Mullvain R. Repatha (evolocumab): A Focused Clinical Review. Presented at the Academy of Managed Care Pharmacy (AMCP) 2017 Annual Meeting; March 27-30, 2017; Denver, CO.
2. Stone NJ, Robinson JG, Lichtenstein AH, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25 pt B):2889-2934. doi: 10.1016/j.jacc.2013.11.002.
3. Repatha [package insert]. Thousand Oaks, CA: Amgen, Inc; July 2016.
4. Robinson JG, Nedergaard BS, Rogers WJ, et al; LAPLACE-2 Investigators. Effect of evolocumab or ezetimibe added to moderate- or high-intensity statin therapy on LDL-C lowering in patients with hypercholesterolemia: the LAPLACE-2 randomized clinical trial. JAMA. 2014;311(18):1870-1882. doi: 10.1001/jama.2014.4030.
5. Blom DJ, Hala T, Bolognese M, et al; DESCARTES Investigators. A 52-week placebo-controlled trial of evolocumab in hyperlipidemia. N Engl J Med. 2014;370(19):1809-1819. doi: 10.1056/NEJMoa1316222.
6. Raal FJ, Stein EA, Dufour R, et al; RUTHERFORD-2 Investigators. PCSK9 inhibition with evolocumab (AMG 145) in heterozygous familial hypercholesterolaemia (RUTHERFORD-2): a randomised, double-blind, placebo-controlled trial. Lancet. 2015;385(9965):331-340. doi: 10.1016/S0140-6736(14)61399-4.
7. Raal FJ, Honarpour N, Blom DJ, et al; TESLA Investigators. Inhibition of PCSK9 with evolocumab in homozygous familial hypercholesterolaemia (TESLA Part B): a randomised, double-blind, placebo-controlled trial. Lancet. 2015;385(9965):341-350. doi: 10.1016/S0140-6736(14)61374-X.

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