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

When your cholesterol won’t budge and statins make your muscles ache, bempedoic acid (sold as Nexletol) can feel like a lifeline. It’s designed for people who can’t take statins - and it works. But here’s the catch: it comes with risks you won’t find on a typical cholesterol pill. Gout flares. Tendon tears. Even liver stress. If you’re considering this drug, you need to know what’s really going on inside your body - not just the benefits, but the real, documented dangers.

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 an earlier step - ATP-citrate lyase. That means it lowers LDL (bad cholesterol) without entering muscle tissue. That’s why it’s often chosen by people who get muscle pain, weakness, or cramps from statins. In clinical trials, muscle-related side effects dropped from 10-15% with statins to under 6% with bempedoic acid.

But here’s what most patients don’t realize: lowering cholesterol in the liver has side effects elsewhere. When the liver makes less cholesterol, it also changes how it handles uric acid. That’s where gout comes in.

Gout: The Most Common Serious Side Effect

One in every 67 people taking bempedoic acid will get gout. That’s 1.5% - more than triple the rate of placebo. For people who’ve had gout before, the risk jumps to 2.3%. That’s not rare. That’s common enough that your doctor should be talking about it before you even start the pill.

Gout happens when uric acid builds up and forms sharp crystals in your joints - usually the big toe. The pain hits fast: swelling, redness, burning so intense you can’t even sleep. Clinical trials show these flares often start within the first four weeks of taking bempedoic acid. It’s not just discomfort. It’s debilitating.

And here’s the kicker: many doctors don’t screen for it. The FDA requires baseline and 4-week uric acid checks, but not every prescriber follows through. If your uric acid level rises above 7 mg/dL, you’re at high risk. Prophylactic allopurinol (a gout-prevention drug) cuts gout risk by 65% in patients on bempedoic acid. Ask your doctor if you need it.

Tendon Rupture: A Silent, Devastating Risk

While gout is painful, tendon rupture is life-changing. In trials, 0.7% of people taking bempedoic acid had tendon injuries - seven times higher than placebo. That’s one in every 140 people. And if you’re taking it with a statin? The risk triples.

Tendons connect muscle to bone. The Achilles tendon in the heel is most vulnerable. Symptoms? A sudden “pop” or snap. Swelling. Bruising. Inability to stand on your toes. It’s not a strain. It’s a tear. And it often requires surgery.

People on fluoroquinolone antibiotics (like ciprofloxacin or levofloxacin) are at even higher risk. The European Atherosclerosis Society says to avoid bempedoic acid entirely if you’re on these drugs. Even if you’re not, any unexplained tendon pain - especially in the heel, shoulder, or wrist - should be treated as a red flag. Stop the drug. See a doctor. Don’t wait.

Other Side Effects You Can’t Ignore

Beyond gout and tendons, here’s what else shows up in clinical data:

• Back pain - nearly 5% of users report it, compared to 2.6% on placebo.
• Muscle spasms - 5.8% vs. 2.5%. Often mild, but can linger for weeks.
• Elevated liver enzymes - 2.2% of users had ALT or AST levels over three times normal. That’s liver stress. Monitoring every 3 months is required.
• Anemia - mild, in 1.8% of cases. Hemoglobin drops slightly, but rarely needs treatment.
• Upper respiratory infections - 7.7% of users got colds or bronchitis. Coincidence? Maybe. But it’s consistent across trials.

Some side effects fade. Muscle spasms often improve after 2-4 weeks. But tendon and gout risks don’t go away with time. They grow with use.

Who Should Avoid Bempedoic Acid?

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

• Have a history of gout - especially if you’ve had multiple flares.
• Are currently taking fluoroquinolone antibiotics.
• Have a prior tendon injury or tendonitis.
• Already have liver disease or unexplained elevated liver enzymes.
• Are pregnant or breastfeeding - safety data is limited.

Even if you don’t fit these categories, you still need monitoring. Baseline blood tests. Uric acid check at 4 weeks. Liver function every 3 months. If your numbers creep up, your doctor should consider stopping the drug - not just adding more meds.

How It Compares to Other Cholesterol Drugs

Compared to ezetimibe (another non-statin option), bempedoic acid lowers LDL about the same - around 17-22%. But it’s worse on gout and tendons:

Statins still lower LDL more aggressively - up to 30-50%. But if you can’t tolerate them, bempedoic acid is the next best option. Just know you’re trading muscle pain for gout and tendon risks.

What to Do If You’re Already Taking It

If you’re on bempedoic acid and feel fine, don’t panic. But do this:

1. Check your uric acid level - if you haven’t had it tested in the last 3 months, ask for it.
2. Review your tendon health. Any recent heel, shoulder, or wrist pain? Tell your doctor.
3. Don’t take fluoroquinolones (cipro, levaquin, etc.) without talking to your cardiologist.
4. Stay active, but avoid sudden intense movements. Stretch your calves and shoulders daily.
5. Report any sudden sharp pain, popping sound, or swelling in a joint or tendon - immediately.

Most people tolerate it fine. But the ones who don’t? They often wait too long to speak up.

The Bigger Picture: Is It Worth It?

The CLEAR Outcomes trial showed bempedoic acid reduces heart attacks, strokes, and heart-related deaths by 13%. That’s real. For someone with a history of heart disease who can’t take statins, that’s life-saving.

But if you’re young, have no heart disease, and just have high cholesterol? The risks might outweigh the benefits. The American Heart Association says bempedoic acid should be reserved for statin-intolerant patients - not used as a first-line option.

It’s not a miracle drug. It’s a tool. A tool with sharp edges. Use it only when necessary. Monitor it closely. And never ignore the warning signs.