Can Repatha Substitute for Statins to Lower Cholesterol?

Not everyone can tolerate statins to lower cholesterol. Some people react to drugs like atorvastatin, lovastatin, pravastatin, rosuvastatin or simvastatin with muscle pain and weakness, arthritis, muscle cramps, digestive distress or neuropathy . Others complain of cognitive problems or forgetfulness. Evolocumab (Repatha) was approved by the FDA on August 27, 2015. It can be prescribed to people who have “established cardiovascular disease to reduce the risk” of heart attacks, strokes or the need for angioplasty and coronary stents. It is also approved as an “adjunct” to diet and other cholesterol-lowering medications such as statins. But what about all by itself? Will Repatha substitute for statins?

Statin Side Effects vs. Repatha?

Over the last few decades we have received thousands of complaints about cholesterol-lowering drugs. We do not know why doctors hate stories of statin side effects so much. You can read about them here. But all drugs have the potential to cause adverse reactions in some people. When that occurs, the prescriber has to find an alternate therapy.

This reader wants to know: will Repatha substitute for statins?

Q. For years I took various statin meds such as atorvastatin. I suffered many side effects such as muscle pain and mental fog.
Now my doctor has recommended that I stop taking the statin. Instead, he wants me to take Repatha. What are the side effects of that drug? Am I jumping from the frying pan into the fire?

A. Many readers have complained about statin side effects like those you mentioned. Two non-statin cholesterol-lowering drugs are PCSK9 inhibitors. They include evolucumab (Repatha) and alirocumab (Praluent). They are injected once or twice a month.

Side effects of Repatha may include:

runny nose
sore throat
flu-like symptoms
sinusitis, cough
headache
dizziness
back pain
muscle pain
injection site reactions.

The most serious side effect is a serious allergic reaction. Muscle pain and spasms can also occur with Praluent.

To learn more about statins and these newer medications, you may find our eGuide to Cholesterol Control and Heart Health useful. This online resource may be found under the Health eGuides tab. You will discover many non-drug approaches along with other medicines that can help reduce cardiovascular risks.

This reader shares a success story with Repatha alone.

Repatha Instead of Statins:

Q. I have been plagued with high cholesterol most of my life. Doctors put me on statins and the result was terrible pain and loss of short-term memory.
The statins lowered my cholesterol from the 300s down into the 200s, but the side effects were totally unacceptable. Switching statins and lowering the dosage didn’t help.
My new doctor prescribed Repatha and within six weeks my cholesterol dropped to 107 with no side effects. I have been on Repatha for six months now and can’t say enough about the new treatment.

A. Evolocumab (Repatha) is approved for people with heart disease or those who have familial (inherited) super-high cholesterol.

Repatha is usually prescribed together with a statin. However, some doctors are prescribing it for patients who can’t tolerate statin side effects. Is it kosher to have Repatha substitute for statins? There is no good answer. A study published in the New England Journal of Medicine (May 4, 2017) showed that Repatha plus a statin reduced heart attacks, strokes and the need for stents more than placebo plus statin.

Doctors can prescribe medications any way they deem appropriate. The FDA’s “indications” are guidelines or recommendations. Drugs get approval for specific indications based on clinical trials. We cannot tell you how well Repatha works all by itself. How well did Repatha work when combined with a statin?

What About Absolute vs. Relative Risk Reduction?

It is crucial for physicians and patients to understand the difference between relative risk reduction and absolute risk reduction. The FOURIER study published in the New England Journal of Medicine reveals some interesting stats. Remember, this study involved a statin plus Repatha.

The relative risk reduction for a stent, stroke or heart attack was between 21 and 27 percent. Sounds impressive. But the absolute risk reduction was 1.5 out of 100. Confused? Here is an article that explains the pros and cons of Repatha in greater detail and this absolute vs. relative thing.

Does the New Cholesterol Drug Repatha Save Lives?

What Do Readers Say About Repatha Side Effects?

Side effects are relatively uncommon. Some people experience serious allergic reactions, flu-like symptoms such as sore throat and cough, back pain, headache, muscle pain, dizziness or digestive distress. That comes from the official prescribing information based on clinical trial data.

Here are some reports from real patients:

Jean describes muscle pain associated with this class of medications (PCSK9 inhibitors):

“My husband had been on statins which caused severe muscle pain. For the last 2 or 3 years he has been on Repatha. He has persistent muscle pain, especially in his legs, that keeps him awake at night.
After reading your article about Repatha, I did some research and found evidence that those who had muscle pain on statins are more likely to have the same side effect on Repatha.”

The article Jean refers to was published in Federal Practitioner (Feb. 2023).

The authors conclude:

“We found that muscle-related PCSK9i AEs [adverse events] occurred at a similar rate as those reported in previous clinical trials and exceeded the incidence rate reported in the prescribing information for alirocumab [Praluent] and evolocumab [Repatha]. It appears that patients who have a prior muscle-related intolerance to a statin and/or ezetimibe [Zetia] had a higher likelihood of developing a muscle-related PCSK9i AE.”

In other words, Jean was right that people who experienced muscle pain on statins were more likely to also experience muscle pain on this class of medicines (PCSK9 inhibitors).

Prentice says he had no obvious side effects while taking Repatha:

“My cholesterol levels were above 230 when I first started Repatha. I had a problem with statin drugs for a few years before, so my doctor thought it might be a good treatment. It took six months to get approval from the insurance company. My LDL is now below 40 with no noticeable side effects.”

Melinda reports a problem with urinary tract infections while taking Repatha. It is listed as a potential adverse reaction in the official prescribing information:

“I have been on Repatha for some time. I didn’t think I was having any negative side effects; however, when I saw your article that urinary tract infections were a side effect I was shocked.
“I have had chronic UTI’s for several years…now I need to talk to my urologist about this (and my cardiologist).
“BTW, Repatha is good at bringing down the numbers.”

Gerald also reports muscle pain on Repatha:

“I took Repatha for 2 months. I woke up one morning in so much muscle and joint pain that my wife had to help me out of bed. I’m talking pain in the 8-10 level. I’ve never hurt so bad in all of my life. My wife had to dress me!
“After being off of Repatha for 7 months I still have pain in my muscles and joints. My doctor said that some people have severe reactions to this drug. The pain has been reduced to less than 25 % of what it was. If it hadn’t been for the fact that I was able to take some pretty potent pain killers, I don’t know what I would have done.
“Some people have had no severe side effects and I’m happy for them but there is no way that I would ever recommend this medication to anyone. I had no hint that this medication was attacking my body.”

Sherry’s doctor wondered, could Repatha substitute for statins? The answer, yes!

“I have had high cholesterol since my early 30’s (familial hypercholesterolemia) and have been on statins since then as well. For the past 15 years or more I was on atorvastatin 80 mg a day along with Vascepa for my triglycerides. It was near impossible for me to even get down to 200 for cholesterol or under 200 for my triglycerides even with all those meds.
“My doctor finally decided to put me on Repatha and stopped the Lipitor. I have been on it for about 5 months or so taking an injection every other week. I cannot believe the difference it has made. This past week my cholesterol came back as 132! I haven’t had any side effects that I know of. I hope this stuff keeps me alive longer because my family is riddled with atherosclerosis.” :(

If insurance covers the cost of Repatha, you are fortunate. Otherwise the drug is very expensive. As we write this, GoodRx reports the retail cost of Repatha (2 sureclicks) is over $600.