Nustendi

Bempedoic acid, ezetimibe.

Each film-coated tablet of Nustendi contains 180 mg of bempedoic acid and 10 mg of ezetimibe.
Nustendi tablets, for oral use, contain bempedoic acid, an adenosine triphosphate-citrate lyase (ACL) inhibitor, and ezetimibe, a dietary cholesterol absorption inhibitor.
The chemical name for bempedoic acid is 8-hydroxy-2,2,14,14-tetramethyl-pentadecanedioic acid. The molecular formula is C₁₉H₃₆O₅, and the molecular weight is 344.5 grams per mole. Bempedoic acid is a white to off-white crystalline powder that is highly soluble in ethanol, isopropanol and pH 8.0 phosphate buffer, and insoluble in water and aqueous solutions below pH 5.
The chemical name for ezetimibe is 1-(4-fluorophenyl)-3(R)-[3-(4-fluorophenyl)-3(S)-hydroxypropyl]-4(S)-(4-hydroxyphenyl)-2-azetidinone. The molecular formula is C₂₄H₂₁F₂NO₃ and the molecular weight is 409.4 grams per mole. Ezetimibe is a white crystalline powder that is freely to very soluble in ethanol, methanol and acetone, and practically insoluble in water.
Excipients/Inactive Ingredients: Each film-coated tablet of Nustendi contains the following inactive ingredients: colloidal silicon dioxide, hydroxy propyl cellulose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, povidone K30, sodium lauryl sulfate, sodium starch glycolate. The film-coating comprises of FD&C Blue #1/Brilliant Blue FCF Aluminum Lake, FD&C Blue #2/Indigo Carmine Aluminum Lake, glyceryl monocaprylocaprate, partially hydrolyzed polyvinyl alcohol, sodium lauryl sulfate, talc, and titanium dioxide.

Pharmacology: Mechanism of Action: Nustendi contains bempedoic acid and ezetimibe. Nustendi reduces elevated LDL-C through inhibition of cholesterol synthesis in the liver and absorption in the intestine.
Bempedoic acid: Bempedoic acid is an adenosine triphosphate-citrate lyase (ACL) inhibitor that lowers low-density lipoprotein cholesterol (LDL-C) by inhibition of cholesterol synthesis in the liver. ACL is an enzyme upstream of 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase in the cholesterol biosynthesis pathway. Bempedoic acid and its active metabolite, ESP15228, require coenzyme A (CoA) activation by very long-chain acyl-CoA synthetase 1 (ACSVL1) to ETC-1002-CoA and ESP15228-CoA, respectively. ACSVL1 is expressed primarily in the liver. Inhibition of ACL by ETC-1002-CoA results in decreased cholesterol synthesis in the liver and lowers LDL-C in blood via upregulation of low-density lipoprotein receptors.
Ezetimibe: Ezetimibe reduces blood cholesterol by inhibiting the absorption of cholesterol by the small intestine. The molecular target of ezetimibe has been shown to be the sterol transporter, Niemann-Pick C1-Like 1 (NPC1L1), which is involved in the intestinal uptake of cholesterol and phytosterols. Ezetimibe localizes at the brush border of the small intestine and inhibits the absorption of cholesterol, leading to a decrease in the delivery of intestinal cholesterol to the liver. This causes a reduction of hepatic cholesterol stores and an increase in LDL receptors, resulting in clearance of cholesterol from the blood.
Pharmacodynamics: Administration of bempedoic acid and ezetimibe in combination with maximally tolerated statins, with or without other lipid-modifying agents, decreases LDL-C, non-high-density lipoprotein cholesterol (non-HDL-C), apolipoprotein B (apo B), and total cholesterol (TC) in patients with hyperlipidemia.
Cardiac Electrophysiology: A QT trial has been conducted for bempedoic acid. At a dose of 240 mg (1.3 times the approved recommended dose), bempedoic acid does not prolong the QT interval to any clinically relevant extent.
The effect of ezetimibe or Nustendi on QT interval has not been evaluated.
Clinical Studies: The efficacy of Nustendi was investigated in a single, multi-center, randomized, double-blind, placebo-controlled, parallel group trial that enrolled 301 patients with heterozygous familial hypercholesterolemia, established atherosclerotic cardiovascular disease, or multiple risk factors for cardiovascular disease on maximally tolerated statin therapy. The efficacy of Nustendi in patients with multiple risk factors for cardiovascular disease has not been established.
Study 1 (NCT03337308) was a 4-arm, 12-week trial that assessed the efficacy of Nustendi in 301 patients randomized 2:2:2:1 to receive either Nustendi (180 mg of bempedoic acid and 10 mg of ezetimibe) (n = 86), bempedoic acid 180 mg (n = 88), ezetimibe 10 mg (n = 86), or placebo (n = 41) once daily as add-on to maximally tolerated statin therapy. Patients were stratified by cardiovascular risk and baseline statin intensity. Patients on simvastatin 40 mg per day or higher and patients taking non-statin lipid-lowering therapy (including fibrates, niacin, bile acid sequestrants, ezetimibe, and PCSK9 inhibitors) were excluded from the trial.
Overall, the mean age at baseline was 64 years (range: 30 to 87 years), 50% were ≥65 years old, 50% were women, 12% Hispanic, 81% White, 17% Black, and 1% Asian. Sixty-two percent (62%) of patients had clinical atherosclerotic cardiovascular disease (ASCVD) and/or a diagnosis of heterozygous familial hypercholesterolemia (HeFH). The mean baseline LDL-C was 149.7 mg/dL. At the time of randomization, 65% of patients were receiving statin therapy and 35% were receiving high-intensity statin therapy.
The primary efficacy outcome measure of the study was the percent change from baseline to Week 12 in LDL-C. The difference between Nustendi and placebo in mean percent change in LDL-C from baseline to Week 12 was -38% (95% CI: -47%, -30%; p < 0.001). High-density lipoprotein (HDL) and triglycerides (TG) were examined as exploratory endpoints and were not included in the statistical hierarchy. The difference between Nustendi and placebo in mean percent change from baseline to Week 12 was -5% for HDL and median percent change from baseline to Week 12 was -11% for TG. The maximum LDL-C lowering effect was observed at Week 4. For additional results, see Table 1.

Click on icon to see table/diagram/image

Examination of age, gender, and race subgroups did not identify differences in response to Nustendi among these subgroups in any of the trials.
Bempedoic Acid: In two 52-week trials that included 3009 adult patients with heterozygous familial hypercholesterolemia or established atherosclerotic cardiovascular disease on maximally tolerated statin therapy, the difference between bempedoic acid and placebo in mean percent change in LDL-C from baseline to Week 12 was -17% to -18%. Bempedoic acid also significantly lowered non-HDL-C (-13%), apo B (-12% to -13%), and TC (-11%) compared with placebo.
Ezetimibe: Ezetimibe Added to On-going Statin Therapy: In a multicenter, double-blind, placebo-controlled, 8-week study, 769 patients with primary hyperlipidemia, known coronary heart disease or multiple cardiovascular risk factors who were already receiving statin monotherapy, but who had not met their NCEP ATP II target LDL-C goal, were randomized to receive either ezetimibe or placebo in addition to their on-going statin therapy.
Ezetimibe, added to on-going statin therapy, significantly lowered TC (-17%), LDL-C (-25%), apo B (-19%), non-HDL-C (-23%), and TG (-14%), and increased HDL-C (+3%) relative to baseline and compared with a statin administered alone. LDL-C reductions induced by ezetimibe were generally consistent across all statins.
Ezetimibe Initiated Concurrently with a Statin: In four, multicenter, double-blind, placebo-controlled, 12-week trials, in 2382 hyperlipidemic patients, ezetimibe or placebo was administered alone or with various doses of atorvastatin, simvastatin, pravastatin, or lovastatin. When all patients receiving ezetimibe with a statin were compared to all those receiving the corresponding statin alone, ezetimibe significantly lowered LDL-C (ezetimibe + all atorvastatin doses [-56%] versus all atorvastatin doses alone [-44%]; ezetimibe + all simvastatin doses [-51%] versus all simvastatin doses alone [-36%]; ezetimibe + all pravastatin doses [-39%] versus all pravastatin doses alone [-25%]; ezetimibe + all lovastatin doses [-40%] versus all lovastatin doses alone [-25%]). LDL-C reductions induced by ezetimibe were generally consistent across all statins.
Pharmacokinetics: Absorption: Nustendi: The bioavailability of Nustendi tablets was similar relative to that from the individual tablets, co-administered. Maximum plasma concentration (C_max) values for bempedoic acid and its active metabolite (ESP15228) were similar between formulations, but ezetimibe-glucuronide and ezetimibe C_max values were approximately 22% and 13% lower, respectively, for Nustendi relative to the individual tablets, co-administered. Given a similar overall extent of ezetimibe-glucuronide and ezetimibe exposure (as measured by AUC), a 22% lower C_max is unlikely to be clinically significant.
Bempedoic acid: Following single oral administration of Nustendi (180 mg of bempedoic acid and 10 mg of ezetimibe), mean (± SD) C_max and AUC of bempedoic acid were 12.6 (± 2.80) μg/mL and 202 (± 43.4) μg·hr/mL, respectively; the median time to maximum concentration (T_max) was 3.0 hours. Following multiple-dose administration of bempedoic acid monotherapy, the steady-state maximum plasma concentration (C_max) and AUC at 180 mg/day were 20.6 ± 6.1 μg/mL and 289.0 ± 96.4 μg·h/mL, respectively. Bempedoic acid steady-state pharmacokinetics were generally linear over a range of >60 mg to 220 mg (approximately 33% to 122% of the recommended dosage of 180 mg daily). There were no time-dependent changes in bempedoic acid pharmacokinetics following repeat administration at the recommended dosage, and bempedoic acid steady-state was achieved after 7 days. The mean accumulation ratio was approximately 2.3-fold.
The steady-state C_max and AUC of the active metabolite (ESP15228) of bempedoic acid were 2.8 ± 0.9 μg/mL and 51.2 ± 17.2 μg·h/mL, respectively. ESP15228 likely made a minor contribution to the overall clinical activity of bempedoic acid based on systemic exposure, relative potency, and pharmacokinetic properties.
Ezetimibe: After a single dose of Nustendi to fasted adults, mean ± SD ezetimibe C_max of 3.56 ± 1.90 ng/mL were attained with a median T_max of 5 hr. Ezetimibe-glucuronide mean C_max values of 107 ± 46 ng/mL were achieved with a median T_max of 1 hr. For ezetimibe monotherapy, there was no substantial deviation from dose proportionality between 5 mg and 20 mg (0.5- to 2-fold the recommended dosage). The absolute bioavailability of ezetimibe cannot be determined, as the compound is virtually insoluble in aqueous media suitable for injection.
Effect of Food: Nustendi: After the administration of Nustendi with a high-fat, high-calorie breakfast in healthy subjects, the AUC for bempedoic acid and ezetimibe were comparable to the fasted state. Compared to the fasted state, the fed state resulted in 30% and 12% reductions in C_max and 2-hour and 2.5-hour delays in median time to attain maximum concentration (T_max) of bempedoic acid and ezetimibe, respectively. For ezetimibe-glucuronide, a 12% and 42% decrease in AUC and C_max, respectively, were observed under fed relative to fasted conditions.
This effect of food is not considered to be clinically meaningful.
Distribution: Bempedoic acid: The bempedoic acid apparent volume of distribution (V/F) was 18 L. Plasma protein binding of bempedoic acid, its glucuronide and its active metabolite, ESP15228, were 99.3%, 98.8% and 99.2%, respectively. Bempedoic acid does not partition into blood cells.
Ezetimibe: Ezetimibe and ezetimibe-glucuronide are highly bound (>90%) to human plasma proteins.
Elimination: Bempedoic acid: The steady-state clearance (CL/F) of bempedoic acid was 11.2 mL/min after once-daily dosing; renal clearance of unchanged bempedoic acid represented less than 2% of total clearance. The mean ± SD half-life for bempedoic acid in humans was 21 ± 11 hours at steady-state.
Ezetimibe: Both ezetimibe and ezetimibe-glucuronide are eliminated from plasma with a half-life of approximately 22 hours for both.
Metabolism: Bempedoic acid: The primary route of elimination for bempedoic acid is through metabolism to the acyl glucuronide. Bempedoic acid is also reversibly converted to an active metabolite (ESP15228) based on aldo-keto reductase activity observed in vitro from human liver. Mean plasma AUC metabolite/parent drug ratio for ESP15228 following repeat-dose administration was 18% and remained constant over time. Both bempedoic acid and ESP15228 are converted to inactive glucuronide conjugates in vitro by UGT2B7. Bempedoic acid, ESP15228 and their respective conjugated forms were detected in plasma with bempedoic acid accounting for the majority (46%) of the AUC_0-48h and its glucuronide being the next most prevalent (30%). ESP15228 and its glucuronide represented 10% and 11% of the plasma AUC_0-48h, respectively.
Ezetimibe: Ezetimibe is primarily metabolized in the small intestine and liver via glucuronide conjugation with subsequent biliary and renal excretion. Minimal oxidative metabolism has been observed in all species evaluated.
In humans, ezetimibe is rapidly metabolized to ezetimibe-glucuronide. Ezetimibe and ezetimibe-glucuronide are the major drug-derived compounds detected in plasma, constituting approximately 10% to 20% and 80% to 90% of the total drug in plasma, respectively. Plasma concentration-time profiles exhibit multiple peaks, suggesting enterohepatic recycling.
Excretion: Bempedoic acid: Following single oral administration of 240 mg of bempedoic acid (1.3 times the approved recommended dose), approximately 70% of the total dose (bempedoic acid and its metabolites) was recovered in urine, primarily as the acyl glucuronide conjugate of bempedoic acid, and approximately 30% was recovered in feces. Less than 5% of the administered dose was excreted as unchanged bempedoic acid in feces and urine combined.
Ezetimibe: Following oral administration of ¹⁴C-ezetimibe (20 mg) to human subjects, total ezetimibe (ezetimibe + ezetimibe-glucuronide) accounted for approximately 93% of the total radioactivity in plasma. Approximately 78% and 11% of the administered radioactivity were recovered in the feces and urine, respectively, over a 10-day collection period. After 48 hours, there were no detectable levels of radioactivity in the plasma.
Ezetimibe was the major component in feces and accounted for 69% of the administered dose, while ezetimibe-glucuronide was the major component in urine and accounted for 9% of the administered dose.
Specific Populations: Patients with Renal Impairment: Bempedoic acid: Pharmacokinetics of bempedoic acid was evaluated in a single-dose pharmacokinetic study in subjects with varying degrees of renal function. The mean bempedoic acid AUC in subjects with mild renal impairment (n = 8) were 1.5-fold higher compared to those with normal renal function (n = 6). Relative to those with normal renal function, mean bempedoic acid AUCs were higher in patients with moderate (n = 5) or severe (n = 5) renal impairment by 2.3-fold and 2.4-fold, respectively.
A population pharmacokinetic analysis was performed on pooled data from all clinical trials (n = 2261) to further evaluate the effects of renal function on the steady-state AUC of bempedoic acid. Compared to patients with normal renal function, the mean bempedoic acid exposures were higher in patients with mild or moderate renal impairment by 1.4-fold (90% CI: 1.3, 1.4) and 1.9-fold (90% CI: 1.7, 2.0), respectively. These differences were not clinically significant. Clinical studies of bempedoic acid did not include patients with severe renal impairment (eGFR <30 mL/min/1.73 m²) or patients with ESRD on dialysis [see Renal Impairment under Precautions].
Ezetimibe: After a single 10 mg dose of ezetimibe in patients with severe renal disease (n = 8; mean CrCl ≤30 mL/min/1.73 m²), the mean AUC for total ezetimibe, ezetimibe-glucuronide, and ezetimibe increased approximately 1.5-fold, compared to healthy subjects (n = 9). No dosage adjustment is necessary for the ezetimibe component. However, there is limited experience with bempedoic acid in patients with severe renal impairment [see Renal Impairment under Precautions].
Patients with Hepatic Impairment: Nustendi is not recommended in patients with moderate or severe hepatic impairment due to the unknown effects of the increased exposure to ezetimibe [see Hepatic Impairment under Precautions].
Bempedoic acid: The pharmacokinetics of bempedoic acid and its metabolite (ESP15228) was studied in patients with normal hepatic function or mild or moderate hepatic impairment (Child-Pugh A or B) following a single dose (n = 8/group). Compared to patients with normal hepatic function, the bempedoic acid mean C_max and AUC were decreased by 11% and 22%, respectively, in patients with mild hepatic impairment and by 14% and 16%, respectively, in patients with moderate hepatic impairment. Compared to patients with normal hepatic function, the ESP15228 mean C_max and AUC were decreased by 13% and 23%, respectively, in patients with mild hepatic impairment and by 24% and 36%, respectively, in patients with moderate hepatic impairment. This is not expected to result in lower efficacy.
Bempedoic acid was not studied in patients with severe hepatic impairment (Child-Pugh C).
Ezetimibe: After a single 10 mg dose of ezetimibe, the mean AUC for total ezetimibe increased approximately 1.7-fold in patients with mild hepatic impairment (Child-Pugh A), compared to healthy subjects. The mean AUC values for total ezetimibe and ezetimibe increased approximately 3- to 4-fold and 5- to 6-fold, respectively, in patients with moderate (Child-Pugh B) or severe hepatic impairment (Child-Pugh C). In a 14-day, multiple-dose study (10 mg daily) in patients with moderate hepatic impairment, the mean AUC for total ezetimibe and ezetimibe increased approximately 4-fold on Day 1 and Day 14 compared to healthy subjects.
Other Specific Populations: Bempedoic acid: The pharmacokinetics of bempedoic acid were not affected by age, gender, race, or weight.
Ezetimibe: Geriatrics: In a multiple-dose study with ezetimibe given 10 mg once daily for 10 days, plasma concentrations for total ezetimibe were about 2-fold higher in older (≥65 years) healthy subjects compared to younger subjects [see Use in the Elderly under Precautions].
Gender: In a multiple-dose study with ezetimibe given 10 mg once daily for 10 days, plasma concentrations for total ezetimibe were slightly higher (<20%) in women than in men.
Race: The pharmacokinetics of ezetimibe is not affected by race.
Drug Interaction Studies: Bempedoic acid: Cytochrome P450 Substrates: In vitro metabolic interaction studies suggest that bempedoic acid, as well as its active metabolite and glucuronide forms, are not metabolized by and do not interact with cytochrome P450 enzymes.
Transporter-mediated Drug Interactions: In vitro drug interaction studies suggest bempedoic acid, as well as its active metabolite and glucuronide form, are not substrates of commonly characterized drug transporters with the exception of bempedoic acid glucuronide, which is an OAT3 substrate. Bempedoic acid weakly inhibits OAT3 at high multiples of clinically relevant concentrations, and bempedoic acid and its glucuronide weakly inhibit OATP1B1, and OATP1B3 at clinically relevant concentrations. Bempedoic acid weakly inhibits OAT2 in vitro, which is likely the mechanism responsible for minor elevations in serum creatinine and uric acid [see Clinical Trials Experience under Adverse Reactions]. Inhibition of OAT2 by bempedoic acid may also potentially increase plasma concentrations of medicinal products that are substrates of OAT2.
Probenecid: Administration of bempedoic acid 180 mg with steady-state probenecid resulted in a 1.7- and a 1.2-fold increase in bempedoic acid AUC and C_max, respectively. AUC and C_max for bempedoic acid active metabolite (ESP15228) were increased 1.9- and 1.5-fold, respectively. These elevations are not clinically meaningful and do not impact dosing recommendations.
Statins: The pharmacokinetic interactions between bempedoic acid (at systemic exposure relevant to the indicated ASCVD population) and simvastatin 20 mg, atorvastatin 10 mg, pravastatin 40 mg, and rosuvastatin 10 mg were evaluated in clinical trials.
Simvastatin: Administration of simvastatin 20 mg with 240 mg of bempedoic acid or 40 mg with 180 mg of bempedoic acid in healthy subjects at steady-state resulted in approximately 2-fold (91% for 20 mg and 96% for 40 mg) and 1.5-fold (54% for 20 mg and 52% for 40 mg) increases in simvastatin acid AUC and C_max, respectively [see Interactions].
Pravastatin: Administration of pravastatin 40 mg with steady-state bempedoic acid 240 mg in healthy subjects resulted in 99% (2-fold) and 104% (2-fold) increases in pravastatin acid AUC and C_max, respectively [see Interactions].
Atorvastatin and Rosuvastatin: Elevations of 1.7-fold in AUC of atorvastatin and rosuvastatin and/or their major metabolites were observed, suggesting a weak interaction. These elevations were generally within the individual statin exposures and do not impact dosing recommendations.
Warfarin: In vitro studies indicate that bempedoic acid is not an inhibitor or inducer of CYP2C9. Because warfarin is primarily eliminated through CYP2C9, its pharmacokinetics is not expected to be altered by bempedoic acid.
Other: Bempedoic acid had no effect on the pharmacokinetics of metformin or the oral contraceptive Ortho-Novum 1/35.
Ezetimibe: Ezetimibe had no significant effect on a series of probe drugs (caffeine, dextromethorphan, tolbutamide, and IV midazolam) known to be metabolized by cytochrome P450 (1A2, 2D6, 2C8/9 and 3A4) in a "cocktail" study of twelve healthy adult males. This indicates that ezetimibe is neither an inhibitor nor an inducer of these cytochrome P450 isozymes, and it is unlikely that ezetimibe will affect the metabolism of drugs that are metabolized by these enzymes.
Cyclosporine: Administration of ezetimibe with cyclosporine (75-150 mg BID) resulted in a 2.4- and a 2.9-fold increase in total ezetimibe AUC and C_max, respectively [see Interactions].
Fibrates: Administration of ezetimibe with fenofibrate (200 mg QD for 14 days) resulted in a 1.48- and a 1.64-fold increase in total ezetimibe AUC and C_max, respectively. Administration with gemfibrozil (600 mg BID for 7 days) resulted in a 1.64- and 1.91-fold increase in total ezetimibe AUC and C_max, respectively [see Interactions].
Cholestyramine: Administration of ezetimibe with cholestyramine (4 g BID for 14 days) resulted in a 55% and a 4% decrease in total ezetimibe AUC and C_max, respectively [see Interactions].
No clinically meaningful pharmacokinetic interaction was observed following co-administration of ezetimibe with aluminum & magnesium hydroxide combination antacid, cimetidine, glipizide, lovastatin, pravastatin, atorvastatin, rosuvastatin, fluvastatin, simvastatin, digoxin, ethyl estradiol/levonorgestrel, and warfarin.
Toxicology: Nonclinical Toxicology: Carcinogenesis, Mutagenesis, Impairment of Fertility: Bempedoic acid: Bempedoic acid was negative for mutagenicity in an in vitro Ames assay and negative for clastogenicity in the in vitro human lymphocyte chromosome aberration assay. Bempedoic acid was negative in both in vivo mouse micronucleus and in vivo rat bone marrow micronucleus/liver comet assay. In a 2-year rat carcinogenicity study, Wistar rats were given oral doses of bempedoic acid at 3, 10 and 30 mg/kg/day. An increased incidence of liver hepatocellular adenomas and hepatocellular adenomas combined with carcinomas, thyroid gland follicular cell adenoma and follicular cell adenomas combined with carcinomas, and pancreatic islet cell adenomas combined with carcinomas were observed in male rats at the dose of 30 mg/kg/day (exposure equivalent to the maximum recommended human dose (MRHD), based on AUC). In a 2-year mice carcinogenicity study, CD-1 mice were given oral doses of bempedoic acid at 25, 75 and 150 mg/kg/day. Bempedoic acid-related increases in the incidence of liver hepatocellular adenomas, hepatocellular carcinomas and hepatocellular adenomas combined with carcinomas in male mice were observed at 75 and 150 mg/kg/day (exposures equivalent to the MRHD). Observations of liver and thyroid tumors are consistent with PPAR alpha agonism in rodents. The human relevance of pancreatic islet cell tumor findings is unknown.
In fertility and early embryofetal development study in rats, bempedoic acid was given orally to male and female rats at 10, 30 and 60 mg/kg/day. Males were dosed for 28 days prior to mating and females were dosed 14 days prior to mating through gestation day 7. No adverse effects on fertility were observed in females in the absence of maternal toxicity. No effects were observed on male fertility outcomes, but decreases in sperm counts were observed at 60 mg/kg/day (9 times the MRHD).
Ezetimibe: A 104-week dietary carcinogenicity study with ezetimibe was conducted in rats at doses up to 1500 mg/kg/day (males) and 500 mg/kg/day (females) (approximately 20 times the human exposure at 10 mg daily based on AUC_0-24hr for total ezetimibe). A 104-week dietary carcinogenicity study with ezetimibe was also conducted in mice at doses up to 500 mg/kg/day (>150 times the human exposure at 10 mg daily based on AUC_0-24hr for total ezetimibe). There were no statistically significant increases in tumor incidences in drug-treated rats or mice.
No evidence of mutagenicity was observed in vitro in a microbial mutagenicity (Ames) test with Salmonella typhimurium and Escherichia coli with or without metabolic activation. No evidence of clastogenicity was observed in vitro in a chromosomal aberration assay in human peripheral blood lymphocytes with or without metabolic activation. In addition, there was no evidence of genotoxicity in the in vivo mouse micronucleus test.
In oral (gavage) fertility studies of ezetimibe conducted in rats, there was no evidence of reproductive toxicity at doses up to 1000 mg/kg/day in male or female rats (approximately 7 times the human exposure at 10 mg daily based on AUC_0-24hr for total ezetimibe).

Nustendi is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia or established atherosclerotic cardiovascular disease who require additional lowering of LDL-C.
Limitations of Use: The effect of Nustendi on cardiovascular morbidity and mortality has not been determined.

Recommended Dosage: The recommended dosage of Nustendi, in combination with maximally tolerated statin therapy, is one tablet orally once daily. One tablet of Nustendi contains 180 mg of bempedoic acid and 10 mg of ezetimibe.
Swallow the tablet whole. Nustendi can be taken with or without food.
After initiation of Nustendi, analyze lipid levels within 8 to 12 weeks.
Co-administration with Bile Acid Sequestrants: Administer Nustendi either at least 2 hours before or at least 4 hours after bile acid sequestrants [see Interactions].

There is no clinical experience with Nustendi overdosage.

Nustendi is contraindicated in patients with a known hypersensitivity to ezetimibe tablets [see Post-marketing Experience under Adverse Reactions]. Hypersensitivity reactions including anaphylaxis, angioedema, rash and urticaria have been reported with ezetimibe.

Hyperuricemia: Bempedoic acid, a component of Nustendi, inhibits renal tubular OAT2 and may increase blood uric acid levels [see Pharmacology: Pharmacokinetics under Actions]. In clinical trials, 26% of bempedoic acid-treated patients with normal baseline uric acid values (versus 9.5% placebo) experienced hyperuricemia one or more times, and 3.5% of patients experienced clinically significant hyperuricemia reported as an adverse reaction (versus 1.1% placebo). Increases in uric acid levels usually occurred within the first 4 weeks of treatment initiation and persisted throughout treatment. After 12 weeks of treatment, the mean placebo-adjusted increase in uric acid compared to baseline was 0.8 mg/dL for patients treated with bempedoic acid.
Elevated blood uric acid may lead to the development of gout. In clinical trials, gout was reported in 1.5% of patients treated with bempedoic acid versus 0.4% of patients treated with placebo. The risk for gout events was higher in patients with a prior history of gout (11.2% bempedoic acid versus 1.7% placebo), although gout also occurred more frequently than placebo in patients treated with bempedoic acid who had no prior gout history (1.0% bempedoic acid versus 0.3% placebo).
Advise patients to contact their healthcare provider if symptoms of hyperuricemia occur. Assess serum uric acid when clinically indicated. Monitor patients for signs and symptoms of hyperuricemia, and initiate treatment with urate-lowering drugs as appropriate.
Tendon Rupture: Bempedoic acid, a component of Nustendi, is associated with an increased risk of tendon rupture or injury. In clinical trials, tendon rupture occurred in 0.5% of patients treated with bempedoic acid versus 0% of placebo-treated patients and involved the rotator cuff (the shoulder), biceps tendon, or Achilles tendon. Tendon rupture occurred within weeks to months of starting bempedoic acid. Tendon rupture may occur more frequently in patients over 60 years of age, in those taking corticosteroid or fluoroquinolone drugs, in patients with renal failure, and in patients with previous tendon disorders.
Discontinue Nustendi immediately if the patient experiences rupture of a tendon. Consider discontinuing Nustendi if the patient experiences joint pain, swelling, or inflammation.
Advise patients to rest at the first sign of tendinitis or tendon rupture and to contact their healthcare provider if tendinitis or tendon rupture symptoms occur. Consider alternative therapy in patients with a history of tendon disorders or tendon rupture.
Renal Impairment: No dosage adjustment is necessary in patients with mild or moderate renal impairment. There is limited experience with bempedoic acid in patients with severe renal impairment (eGFR <30 mL/min/1.73 m²), and bempedoic acid has not been studied in patients with end-stage renal disease (ESRD) receiving dialysis [see Pharmacology: Pharmacokinetics under Actions].
Hepatic Impairment: No dosage adjustment is necessary in patients with mild hepatic impairment (Child-Pugh A) [see Pharmacology: Pharmacokinetics under Actions]. Nustendi is not recommended in patients with moderate or severe hepatic impairment (Child-Pugh B or C) due to the unknown effects of the increased exposure to ezetimibe [see Pharmacology: Pharmacokinetics under Actions].
Use in Children: The safety and effectiveness of Nustendi have not been established in pediatric patients.
Use in the Elderly: Of the 301 patients in the clinical trial of Nustendi, 149 (50%) were 65 and over, while 49 (16%) were 75 and over. No overall differences in safety or effectiveness were observed between these patients and younger patients, and other reported clinical experience has not identified differences in responses between the elderly and younger patients. However, greater sensitivity of some older individuals cannot be ruled out.

Pregnancy: Risk Summary: Discontinue Nustendi when pregnancy is recognized unless the benefits of therapy outweigh the potential risks to the fetus.
There are no available data on bempedoic acid use in pregnant women to evaluate for a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. There are insufficient data on ezetimibe use in pregnant women to evaluate for a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. In animal reproduction studies, bempedoic acid was not teratogenic in rats and rabbits when administered at doses resulting in exposures up to 11 and 12 times, respectively, the human exposures at the maximum clinical dose, based on AUC. In oral (gavage) embryofetal development studies of ezetimibe conducted in rats and rabbits during organogenesis, there was no evidence of maternal toxicity or embryofetal teratogenic or toxicologic effects at exposures up to 10 and 150 times the human exposure, respectively, based on AUC (see Data as follows). Nustendi decreases cholesterol synthesis and possibly the synthesis of other biologically active substances derived from cholesterol; therefore, Nustendi may cause fetal harm when administered to pregnant women based on the mechanism of action [see Pharmacology: Mechanism of Action under Actions]. In addition, treatment of hyperlipidemia is not generally necessary during pregnancy. Atherosclerosis is a chronic process and the discontinuation of lipid-lowering drugs during pregnancy should have little impact on the outcome of long-term therapy of primary hyperlipidemia for most patients.
The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.
Data: Animal Data: Bempedoic acid: Bempedoic acid was not teratogenic when given orally at doses of 60 and 80 mg/kg/day, resulting in 11 and 12 times the systemic exposure in humans at the maximum recommended human dose (MRHD) of 180 mg to pregnant rats and rabbits, respectively. In an embryofetal development study in rats, bempedoic acid was given orally to pregnant rats at 10, 30, and 60 mg/kg/day during the period of organogenesis from gestation day 6 to 17. There were increases in the incidence of non-adverse fetal skeletal variations (bent long bones and bent scapula and incomplete ossification) at doses ≥10 mg/kg/day (less than the clinical exposure) in the absence of maternal toxicity. At maternally toxic doses, bempedoic acid caused decreases in the numbers of viable fetuses, increases in post-implantation loss, and increased total resorptions at 60 mg/kg/day (11 times MRHD) and reduced fetal body weight at ≥30 mg/kg/day (4 times the MRHD). No adverse development effects were observed when bempedoic acid was given to pregnant rabbits during the period of organogenesis (gestation day 6 to 18) at doses up to 80 mg/kg/day (12 times MRHD).
In a pre- and post-natal development study in pregnant rats given oral doses of bempedoic acid at 5, 10, 20, 30 and 60 mg/kg/day throughout pregnancy and lactation (gestation day 6 to lactation day 20), there were adverse effects on delivery in the presence of maternal toxicity, including: increases in stillborn pups, reductions in numbers of live pups, pup survival, pup growth and slight delays in learning and memory at ≥10 mg/kg/day (at exposures equivalent to the MRHD).
Ezetimibe: In oral (gavage) embryofetal development studies of ezetimibe conducted in rats (gestation days 6-15) and rabbits (gestation days 7-19) during organogenesis, there was no evidence of maternal toxicity or embryolethality at any of the doses tested (250, 500, 1000 mg/kg/day) at exposures equivalent to 10 to 150 times the MRHD, based on AUC, in rats and rabbits. In rats, increased incidences of common fetal skeletal findings (extra pair of thoracic ribs, unossified cervical vertebral centra, shortened ribs) were observed at 1000 mg/kg/day (approximately 10 times the human exposure at 10 mg daily based on AUC_0-24hr for total ezetimibe). In rabbits treated with ezetimibe, an increased incidence of extra thoracic ribs was observed at 1000 mg/kg/day (150 times the human exposure at 10 mg daily based on AUC_0-24hr for total ezetimibe). The animal-to-human exposure multiple for total ezetimibe at the no-observed effect level was 6 times for rat and 134 times for rabbit.
Fetal exposure to ezetimibe (conjugated and unconjugated) was confirmed in subsequent placental transfer studies conducted using a maternal dose of 1000 mg/kg/day. The fetal maternal plasma exposure ratio (total ezetimibe) was 1.5 for rats on gestation day 20 and 0.03 for rabbits on gestation day 22.
The effect of ezetimibe on prenatal and postnatal development and maternal function was evaluated in pregnant rats at doses of 100, 300 or 1000 mg/kg/day (gestation day 6 through lactation day 21). No maternal toxicity or adverse developmental outcomes were observed up to and including the highest dose tested (17 times the human exposure at 10 mg daily based on AUC_0-24hr for total ezetimibe).
Multiple-dose studies of ezetimibe co-administered with statins in rats and rabbits during organogenesis result in higher ezetimibe and statin exposures. Reproductive findings occur at lower doses in combination therapy compared to monotherapy.
Bempedoic acid/ezetimibe fixed combination drug product (FCDP): In a combination embryofetal development study in rats, bempedoic acid and ezetimibe were given orally at 4 and 112 times MRHD (based on AUC) during the period of organogenesis (gestation day 6 to 17) in pregnant rats. Bempedoic acid in combination with ezetimibe did not alter the effects on embryofetal development profile of bempedoic acid or ezetimibe.
Lactation: Risk Summary: There is no information regarding the presence of bempedoic acid in human or animal milk, the effects of the drug on the breastfed infant, or the effects of the drug on milk production. There is no information about the presence of ezetimibe in human milk. Ezetimibe is present in rat milk (see Data as follows). When a drug is present in animal milk, it is likely that the drug will be present in human milk. There is no information about the effects of ezetimibe on the breastfed infant or the effects on milk production.
Nustendi decreases cholesterol synthesis and possibly the synthesis of other biologically active substances derived from cholesterol and may cause harm to the breastfed infant. Because of the potential for serious adverse reactions in a breastfed infant, based on the mechanism of action, advise patients that breastfeeding is not recommended during treatment with Nustendi [see Pregnancy as previously mentioned; Pharmacology: Mechanism of Action under Actions].
Data: Animal Data: Ezetimibe was present in the milk of lactating rats. The pup to maternal plasma ratio for total ezetimibe was 0.5 on lactation day 12.

The following clinically significant adverse reactions are described in Precautions: Hyperuricemia; Tendon Rupture.
Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.
Bempedoic acid: The data described as follows reflect exposure to bempedoic acid in two placebo-controlled trials that included 2009 patients treated with bempedoic acid for 52 weeks (median treatment duration of 52 weeks) [see Pharmacology: Pharmacodynamics: Clinical Studies under Actions]. The mean age for bempedoic acid-treated patients was 65.4 years, 29% were women, 3% were Hispanic, 95% White, 3% Black, 1% Asian, and 1% other races. All patients received bempedoic acid 180 mg orally once daily plus maximally tolerated statin therapy alone or in combination with other lipid-lowering therapies. At baseline, 97% of patients had clinical atherosclerotic cardiovascular disease (ASCVD) and about 4% had a diagnosis of heterozygous familial hypercholesterolemia (HeFH). Patients on simvastatin 40 mg/day or higher were excluded from the trials.
Adverse reactions led to discontinuation of treatment in 11% of bempedoic acid-treated patients and 8% of placebo-treated patients. The most common reasons for bempedoic acid treatment discontinuation were muscle spasms (0.5% versus 0.3% placebo), diarrhea (0.4% versus 0.1% placebo), and pain in extremity (0.3% versus 0.0% placebo). Adverse reactions reported in at least 2% of bempedoic acid-treated patients and more frequently than in placebo-treated patients are shown in Table 2. (See Table 2.)

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Tendon Rupture: Bempedoic acid was associated with an increased risk of tendon rupture, occurring in 0.5% of bempedoic acid-treated patients versus 0% of placebo-treated patients.
Gout: Bempedoic acid was associated with an increased risk of gout, occurring in 1.5% of bempedoic acid-treated patients versus 0.4% of placebo-treated patients.
Benign Prostatic Hyperplasia: Bempedoic acid was associated with an increased risk of benign prostatic hyperplasia (BPH) or prostatomegaly in men with no reported history of BPH, occurring in 1.3% of bempedoic acid-treated patients versus 0.1% of placebo-treated patients. The clinical significance is unknown.
Atrial Fibrillation: Bempedoic acid was associated with an imbalance in atrial fibrillation, occurring in 1.7% of bempedoic acid-treated patients versus 1.1% of placebo-treated patients.
Laboratory Tests: Bempedoic acid was associated with persistent changes in multiple laboratory tests within the first 4 weeks of treatment. Laboratory test values returned to baseline following discontinuation of treatment.
Increase in Creatinine and Blood Urea Nitrogen: Overall, there was a mean increase in serum creatinine of 0.05 mg/dL compared to baseline with bempedoic acid at Week 12. Approximately 3.8% of patients treated with bempedoic acid had blood urea nitrogen values that doubled (versus 1.5% placebo), and about 2.2% of patients had creatinine values that increased by 0.5 mg/dL (versus 1.1% placebo).
Decreased Hemoglobin and Leukocytes: Approximately 5.1% of patients treated with bempedoic acid (versus 2.3% placebo) had decreases in hemoglobin levels of 2 or more g/dL and below the lower limit of normal on one or more occasion. Anemia was reported in 2.8% of patients treated with bempedoic acid and 1.9% of patients treated with placebo. Hemoglobin decrease was generally asymptomatic and did not require medical intervention. Decreased leukocyte count was also observed. Approximately 9.0% of bempedoic acid-treated patients with normal baseline leukocyte count had a decrease to less than the lower limit of normal on one or more occasion (versus 6.7% placebo). Leukocyte decrease was generally asymptomatic and did not require medical intervention. In clinical trials, there was a small imbalance in skin or soft tissue infections, including cellulitis (0.8% versus 0.4%), but there was no imbalance in other infections.
Increase in Platelet Count: Approximately 10.1% of bempedoic acid-treated patients (versus 4.7% placebo) had increases in platelet counts of 100 × 10⁹/L or more on one or more occasion. Platelet count increase was asymptomatic, did not result in increased risk for thromboembolic events, and did not require medical intervention.
Increase in Liver Enzymes: Increases in hepatic transaminases (AST and/or ALT) were observed with bempedoic acid. In most cases, the elevations were transient and resolved or improved with continued therapy or after discontinuation of therapy. Increases to more than 3× the upper limit of normal (ULN) in AST occurred in 1.4% of patients treated with bempedoic acid versus 0.4% of placebo patients, and increases to more than 5× ULN occurred in 0.4% of bempedoic acid-treated versus 0.2% of placebo-treated patients. Increases in ALT occurred with similar incidence between bempedoic acid- and placebo-treated patients. Elevations in transaminases were generally asymptomatic and not associated with elevations ≥2× ULN in bilirubin or with cholestasis.
Increase in Creatine Kinase: Approximately 1.0% of patients (versus 0.6% placebo) had elevations of CK levels of 5 or more times the normal value on one or more occasions, and 0.4% of patients (versus 0.2% placebo) had elevations of CK levels of 10 or more times.
Ezetimibe: In 10 double-blind, placebo-controlled clinical trials, 2396 patients with primary hyperlipidemia (age range 9-86 years, 50% women, 90% Caucasians, 5% Blacks, 3% Hispanics, 2% Asians) and elevated LDL-C were treated with ezetimibe 10 mg/day for a median treatment duration of 12 weeks (range 0 to 39 weeks).
Adverse reactions led to discontinuation of treatment in 3.3% of ezetimibe-treated patients and 2.9% of placebo-treated patients. The most common reasons for ezetimibe treatment discontinuation were arthralgia (0.3%), dizziness (0.2%), and gamma-glutamyltransferase increased (0.2%). Adverse reactions reported in ≥2% of patients treated with ezetimibe and at an incidence greater than placebo in placebo-controlled studies of ezetimibe, regardless of causality assessment, are shown in Table 3. (See Table 3.)

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The frequency of less common adverse reactions was comparable between ezetimibe and placebo.
Nustendi: In a 4-arm, 12-week, randomized, double-blind, placebo-controlled, parallel group, factorial trial, 85 patients received Nustendi (180 mg of bempedoic acid and 10 mg of ezetimibe) once daily [see Pharmacology: Pharmacodynamics: Clinical Studies under Actions]. The mean age for Nustendi-treated patients was 62 years, 51% were women, 12% Hispanic, 78% White, 19% Black, and 2% Asian. At baseline, 61% of patients had clinical atherosclerotic cardiovascular disease (ASCVD) and/or a diagnosis of heterozygous familial hypercholesterolemia. All patients received Nustendi plus maximally tolerated statin therapy. Patients taking simvastatin 40 mg/day or higher and patients taking non-statin lipid-lowering therapy (including fibrates, niacin, bile acid sequestrants, ezetimibe, and PCSK9 inhibitors) were excluded from the trial.
Adverse reactions led to discontinuation of treatment in 8% of patients on Nustendi, 5% of patients on placebo, 10% of patients on bempedoic acid, and 12% of patients on ezetimibe. The most common reason for Nustendi treatment discontinuation was oral discomfort (2% Nustendi versus 0% placebo). The most commonly reported adverse reactions (incidence ≥3% and greater than placebo) observed with Nustendi, but not observed in clinical trials of bempedoic acid or ezetimibe, were urinary tract infection (5.9% Nustendi versus 2.4% placebo), nasopharyngitis (4.7% Nustendi versus 0% placebo), and constipation (4.7% Nustendi versus 0% placebo).
Post-marketing Experience: Because these reactions are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
The following additional adverse reactions have been reported in post-marketing experience for ezetimibe: Hypersensitivity reactions, including anaphylaxis, angioedema, rash, and urticaria; erythema multiforme; myalgia; elevated creatine phosphokinase; myopathy/rhabdomyolysis; elevations in liver transaminases; hepatitis; abdominal pain; thrombocytopenia; pancreatitis; nausea; dizziness; paresthesia; depression; headache; cholelithiasis; cholecystitis.

No specific pharmacokinetic drug interaction studies with Nustendi have been conducted. Drug interactions that have been identified in studies with bempedoic acid or ezetimibe determine the interactions that may occur with Nustendi. (See Table 4.)

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Store below 25°C.
Store in the original package in order to protect from moisture.

Advise patients to read the package insert.
Risk of Hyperuricemia: Advise patients of the risk of elevated serum uric acid levels, including development of gout. Inform patients that serum uric acid levels may be monitored during treatment with Nustendi. Patients with signs or symptoms of hyperuricemia should contact their healthcare provider if symptoms occur [see Hyperuricemia under Precautions].
Risk of Tendon Rupture: Inform patients of the risk of tendon rupture. Advise patients to rest at the first sign of tendinitis or tendon rupture and to immediately contact their healthcare provider if tendinitis or tendon rupture symptoms occur [see Tendon Rupture under Precautions].
Risk of Myopathy with Concomitant Use of Simvastatin or Pravastatin: Advise patients to notify their healthcare provider(s) if they are taking or plan to take simvastatin or pravastatin. The risk of myopathy occurring with the use of simvastatin or pravastatin may be increased when taken with Nustendi [see Interactions].
Pregnancy: Advise pregnant women of the potential risk to a fetus based on Nustendi's mechanism of action. Advise females to inform their healthcare provider of a known or suspected pregnancy [see Pregnancy under Use in Pregnancy & Lactation].

Dyslipidaemic Agents

C10BA10 - bempedoic acid and ezetimibe ; Belongs to the class of HMG CoA reductase inhibitors in combination with other lipid modifying agents. Used in the treatment of hyperlipidemia.

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