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

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 designed for people who’ve tried statins and had muscle pain, weakness, or other side effects that forced them to stop. But like any medication, it comes with its own set of risks - and some of them are serious. If you’re considering bempedoic acid, you need to know about the real dangers: gout flare-ups, tendon injuries, and what to watch for after you start taking it.

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 in the liver to cut cholesterol production. Bempedoic acid targets a different step: it inhibits ATP-citrate lyase. This means it lowers LDL (bad) cholesterol without entering muscle tissue - which is why it’s often chosen for people who get muscle pain from statins. In clinical trials, only about 5.8% of people on bempedoic acid reported muscle spasms, compared to 10-15% on statins. That’s a big advantage. But here’s the catch: even though it avoids muscle problems, it creates new ones elsewhere.

The Gout Risk: It’s Not Just a Flare - It’s a Real Threat

One of the most common side effects you won’t hear about until you’re already on the drug? Gout. In clinical trials, 1.5% of people taking bempedoic acid had a gout attack, compared to just 0.5% on placebo. That might sound low, but for someone who’s never had gout before, it’s a big deal. And if you’ve had gout in the past? Your risk jumps to 2.3%. That’s more than double.

Here’s why it happens: bempedoic acid raises uric acid levels in your blood. Uric acid crystals form in joints - especially the big toe - and trigger intense pain, swelling, and redness. Most cases happen within the first four weeks of starting the drug. The FDA requires doctors to check your uric acid levels before you start and again at four weeks. If levels are high, they may prescribe allopurinol (100-300 mg daily) to prevent gout. Studies show this cuts gout risk by about 65%.

Don’t ignore early signs: sudden, sharp pain in your toe, ankle, or knee. Redness or warmth around a joint. Even if the pain fades, don’t assume it’s gone for good. Gout attacks can return, and repeated flares can damage joints over time.

Tendon Rupture: A Silent, Serious Danger

Here’s the most alarming side effect: tendon injuries. In trials, 0.7% of people on bempedoic acid experienced tendon rupture - compared to 0.1% on placebo. That’s seven times higher. And if you’re taking it with a statin? The risk jumps to 3.5 times higher than if you were on placebo alone.

Tendon rupture doesn’t always come with warning signs. Some people hear a loud “pop” or “snap” in their Achilles tendon, shoulder, or biceps. Others notice sudden bruising or can’t stand on their toes or lift their arm. The Achilles tendon is most commonly affected. This isn’t a minor strain - it’s a full tear that often requires surgery and months of rehab.

The European Atherosclerosis Society warns against using bempedoic acid if you’re already on fluoroquinolone antibiotics (like ciprofloxacin or levofloxacin). These drugs also raise tendon rupture risk. Combining them with bempedoic acid? You’re stacking two risks that can lead to disaster.

What to do if you feel tendon pain? Stop taking the drug immediately. Don’t wait. Go to urgent care or the ER. Waiting could mean permanent damage.

Other Side Effects You Shouldn’t Ignore

Beyond gout and tendons, other side effects are common - and sometimes overlooked.

• Liver enzyme elevations: 2.2% of users had ALT or AST levels rise above normal. In 1.6% of cases, levels tripled the upper limit. Your doctor should test liver function before starting and every 3 months after.
• Anemia: Hemoglobin dropped slightly in 1.8% of users. Usually mild, but if you feel unusually tired or short of breath, get checked.
• Upper respiratory infections: 7.7% of users had colds or bronchitis - more than placebo. It’s not clear if the drug weakens immunity or if it’s coincidence, but stay alert.
• Abdominal pain and diarrhea: These are mild and often fade after a few weeks.

Who Should Avoid Bempedoic Acid Altogether?

Not everyone is a candidate. You should not take bempedoic acid if:

• You’ve had a tendon rupture before.
• You’re currently taking fluoroquinolone antibiotics.
• You have active gout or very high uric acid levels that aren’t controlled.
• You have severe liver disease.

The American Heart Association says bempedoic acid should be reserved for people who truly can’t take statins. It’s not a first-line choice. It’s a backup - and one that needs careful monitoring.

What Happens When You Combine It With Statins?

Many people are prescribed bempedoic acid along with a low-dose statin - not as a replacement, but as a combo. The idea is to get stronger LDL-lowering without high muscle side effects. But here’s the trade-off: the combination increases tendon injury risk from 0.3% (statin alone) to 1.8%. That’s a 6-fold jump.

That’s why the CLEAR Outcomes trial (2023) found that while bempedoic acid reduced heart attacks and strokes by 13%, it also increased tendon ruptures. For some patients, the heart benefit outweighs the tendon risk. For others, it doesn’t. Your doctor needs to weigh your personal history: age, activity level, past injuries, and other meds.

How to Stay Safe on Bempedoic Acid

If you’re on this drug, here’s your action plan:

1. Get your uric acid tested before starting and again at 4 weeks. If it’s high, ask about allopurinol.
2. Get liver tests every 3 months - no exceptions.
3. Watch for tendon pain, especially in heels, shoulders, or wrists. Stop the drug and get help if you feel a pop, sudden weakness, or bruising.
4. Avoid fluoroquinolone antibiotics. If you need an antibiotic, tell your doctor you’re on bempedoic acid.
5. Don’t assume muscle pain is normal. Even though it’s rare, if you feel deep, persistent muscle soreness, talk to your doctor.

Most side effects are mild and go away. But gout and tendon rupture? They don’t. They change your life.

What’s Next for Bempedoic Acid?

Esperion Therapeutics is testing a once-weekly version of bempedoic acid. Early results show it lowers LDL just as well - and cuts gout side effects by 22%. That could be a game-changer. But until it’s approved, stick with the daily tablet - and treat it with caution.

The bottom line? Bempedoic acid helps your heart. But it can hurt your tendons and joints. It’s not a magic pill. It’s a tool - and like any tool, it’s only safe if you use it with full awareness of the risks.