Lipid Management with Repatha (Evolocumab)

Indications and Dosage

The American College of Cardiology recommends a maximum dose of 420 mg of Repatha (evolocumab) administered subcutaneously every 2 weeks for patients with homozygous familial hypercholesterolemia (HoFH) who require additional LDL-C reduction after 12 weeks of monthly therapy 1
For adults with ASCVD or primary hypercholesterolemia, the recommended dose is 140 mg subcutaneously every 2 weeks or 420 mg subcutaneously once monthly, as recommended by the American College of Cardiology 1
Pediatric patients (≥10 years) with heterozygous familial hypercholesterolemia (HeFH) should receive the same dosing as adults: 140 mg every 2 weeks or 420 mg monthly, as recommended by the American College of Cardiology 1

The 420 mg dose can be administered using the prefilled single-dose on-body infuser or by administering three 140 mg injections consecutively within 30 minutes, as recommended by the American College of Cardiology 1
For patients with HoFH on LDL apheresis, the recommended dose is 420 mg every 2 weeks, administered after the apheresis procedure is complete, as recommended by the American College of Cardiology 1

When added to statin therapy, evolocumab 140 mg every 2 weeks and 420 mg every 4 weeks reduces LDL-C by approximately 64% and 58%, respectively, with a favorable safety profile, as reported by the American College of Cardiology 1
The most common adverse effects include nasopharyngitis, upper respiratory tract infection, influenza, back pain, and injection site reactions, as reported by the American College of Cardiology 1
The European Society of Cardiology recommends an LDL-C target of <55 mg/dL and at least 50% reduction from baseline, while the American College of Cardiology and American Heart Association recommend adding a PCSK9 inhibitor when LDL-C remains ≥70 mg/dL despite maximally tolerated statin therapy plus ezetimibe 2, 3, 4, 5

Patients with established ASCVD and LDL-C levels ≥70 mg/dL despite maximally tolerated high-intensity statin therapy and addition of ezetimibe to statin therapy are eligible for further treatment, as recommended by the European Society of Cardiology 5
Patients with documented heterozygous familial hypercholesterolemia (HeFH) and LDL-C ≥100 mg/dL despite maximally tolerated statin plus ezetimibe may also be eligible, as recommended by the American College of Cardiology 6
Priority should be given to patients with established ASCVD and LDL-C ≥70 mg/dL despite maximally tolerated statin plus ezetimibe, patients with familial hypercholesterolemia, and statin-intolerant patients with high cardiovascular risk, as recommended by the American College of Cardiology 7, 8, 9

Regular lipid panel monitoring is recommended to assess response, typically at 4-8 weeks after initiation, according to the Nature Reviews Cardiology guidelines 3
No specific laboratory monitoring is required beyond routine lipid profile assessment, with no requirement for liver function tests, renal function, or complete blood counts, as recommended by the American College of Cardiology 7, 1, 10, 11
Repatha can be safely used in patients with a history of tendinitis, with no known association with tendon disorders, unlike other medications like bempedoic acid, as reported by the American College of Cardiology 1

The medication has demonstrated a 15% relative risk reduction in composite cardiovascular endpoints in the FOURIER trial (HR 0.85, 95% CI 0.79-0.92), and a 20% reduction in the combined endpoint of cardiovascular death, MI, or stroke (HR 0.80, 95% CI 0.73-0.88), as reported by the American College of Cardiology 7, 12, 1
Prior authorization processes for Repatha may be burdensome, and the high cost of evolocumab may restrict its use despite its excellent efficacy and tolerability profile, according to the American College of Cardiology and European Society of Cardiology 13, 1