Nexlizet Mechanism of Action

Pharmacotherapeutic group: Lipid modifying agents in combination with other drugs. ATC code: C10BA10.
Pharmacodynamics: Mechanism of action: Nexlizet contains bempedoic acid and ezetimibe, two LDL-C lowering compounds with complementary mechanisms of action. It reduces elevated LDL-C through dual inhibition of cholesterol synthesis in the liver and cholesterol absorption in the intestine.
Bempedoic acid: Bempedoic acid is an adenosine triphosphate-citrate lyase (ACL) inhibitor that lowers 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 requires coenzyme A (CoA) activation by very long-chain acyl-CoA synthetase 1 (ACSVL1) to ETC-1002-CoA. ACSVL1 is expressed primarily in the liver and not in skeletal muscle. 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. Additionally, inhibition of ACL by ETC-1002-CoA results in concomitant suppression of hepatic fatty acid biosynthesis.
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.
Pharmacodynamic effects: Administration of bempedoic acid and ezetimibe alone and in combination with other lipid modifying medicinal products decreases LDL-C, non-high density lipoprotein cholesterol (non-HDL-C), apolipoprotein B (apo B), and total cholesterol (TC) in patients with hypercholesterolaemia or mixed dyslipidaemia.
Because patients with diabetes are at elevated risk for atherosclerotic cardiovascular disease, the clinical trials of bempedoic acid included patients with diabetes mellitus. Among the subset of patients with diabetes, lower levels of HbA1c were observed as compared to placebo (on average 0.2%). In patients without diabetes, no difference in HbA1c was observed between bempedoic acid and placebo and there were no differences in the rates of hypoglycaemia.
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 the combination regimen bempedoic acid/ezetimibe on QT interval has not been evaluated.
Clinical efficacy and safety: Ezetimibe 10 mg has been shown to reduce the frequency of cardiovascular events.
Clinical efficacy and safety in primary hypercholesterolaemia and mixed dyslipidaemia: The efficacy of Nexlizet was assessed in a sensitivity analysis of 301 patients who received treatment in CLEAR Combo (Study 1002-053). This analysis excluded all data from 3 sites (81 patients) due to systematic patient non-compliance with all the four treatments. The study was a 4-arm, multi-centre, randomised, double-blind, parallel-group, 12-week trial in patients with high cardiovascular risk and hyperlipidaemia. Patients randomised 2:2:2:1, received either Nexlizet orally at a dose of 180 mg/10 mg per day (n=86), bempedoic acid 180 mg per day (n=88), ezetimibe 10 mg per day (n=86), or placebo once daily (n=41) as add-on to a maximum tolerated statin therapy. Maximum tolerated statin therapy could include statin regimens other than daily dosing or no statin. Patients were stratified by cardiovascular risk and baseline statin intensity. Patients on simvastatin 40 mg per day or higher were excluded from the trial.
Demographics and baseline disease characteristics were balanced between the treatment arms. Overall, the mean age at baseline was 64 years (range: 30 to 87 years), 50% were ≥65 years old, 50% were women, 81% were White, 17% were Black, 1% were Asian, and 1% were other. At the time of randomisation, 61% of patients on bempedoic acid/ezetimibe, 69% of patients on bempedoic acid, 63% of patients on ezetimibe and 66% of patients on placebo were receiving statin therapy; 36% of patients on bempedoic acid/ezetimibe, 35% of patients on bempedoic acid, 29% of patients on ezetimibe and 41% of patients on placebo were receiving high intensity statin therapy. The mean baseline LDL-C was 3.9 mmol/L (149.7 mg/dL). Most patients (94%) completed the study.
Nexlizet significantly reduced LDL-C from baseline to week 12 compared with placebo (-38.0%; 95% CI: -46.5%, -29.6%; p <0.001). The maximum LDL-C lowering effects were observed as early as week 4 and efficacy was maintained throughout the trial. Nexlizet also significantly reduced non-HDL-C, apo B, and TC (see Table 1).

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Administration of bempedoic acid on background ezetimibe therapy: CLEAR Tranquility (Study 1002-048) was a multi-centre, randomised, double-blind, placebo-controlled 12-week phase 3 primary hyperlipidaemia study evaluating the efficacy of bempedoic acid versus placebo in lowering LDL-C when added to ezetimibe in patients with elevated LDL-C who had a history of statin intolerance and were unable to tolerate more than the lowest approved starting dose of a statin. The trial included 269 patients randomised 2:1 to receive either bempedoic acid (n=181) or placebo (n=88) as add-on to ezetimibe 10 mg daily for 12 weeks.
Overall, the mean age at baseline was 64 years (range: 30 to 86 years), 55% were ≥65 years old, 61% were women, 89% were White, 8% were Black, 2% were Asian, and 1% were other. The mean baseline LDL-C was 3.3 mmol/L (127.6 mg/dL). At the time of randomisation, 33% of patients on bempedoic acid versus 28% on placebo were receiving statin therapy at less than or equal to lowest approved doses. Administration of bempedoic acid to patients on background ezetimibe therapy significantly reduced LDL-C from baseline to week 12 compared with placebo and ezetimibe (p <0.001). Administration of bempedoic acid with background ezetimibe therapy also significantly reduced non-HDL-C, apo B, and TC (see Table 2).

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Clinical efficacy and safety in prevention of cardiovascular events: CLEAR Outcomes (Study 1002-043) was a multi-centre randomised, double-blind, placebo controlled, event-driven trial in 13 970 adult patients with established atherosclerotic cardiovascular disease (CVD) (70%), or at high risk for atherosclerotic CVD (30%). Patients with established CVD had documented history of coronary artery disease, symptomatic peripheral arterial disease, and/or cerebrovascular atherosclerotic disease. Patients without established CVD were considered at high risk for CVD based on meeting at least one of the following criteria: (1) diabetes mellitus (type 1 or type 2) in women over 65 years of age, or men over 60 years of age, or (2) a Reynolds Risk score >30% or a SCORE Risk score >7.5% over 10 years, or 3) a coronary artery calcium score >400 Agatston units at any time in the past. Patients were randomised 1:1 to receive either bempedoic acid 180 mg per day (n=6,992) or placebo (n=6,978) alone or as an add on to other background lipid lowering therapies that could include very low doses of statins. Overall, more than 95% of patients were followed until the end of the trial or death, and less than 1% were lost to follow up. The median follow-up duration was 3.4 years.
At baseline, the mean age was 65.5 years, 48% were women, 91% were White. Selected additional baseline characteristics included hypertension (85%), diabetes mellitus (46%), pre-diabetes mellitus (42%), current tobacco user (22%), eGFR <60 mL/min per 1.73 m2 (21%), and a mean body mass index 29.9 kg/m2. The mean baseline LDL-C was 3.6 mmol/L (139 mg/dL). At baseline, 41% of patients were taking at least one lipid modifying therapy including ezetimibe (12%), and very low dose of statins (23%).
Bempedoic acid significantly reduced the risk for the primary composite endpoint of major adverse cardiovascular events (MACE-4) consisting of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or coronary revascularization by 13% compared to placebo (Hazard Ratio: 0.87; 95% CI: 0.79, 0.96; p=0.0037); and the risk of the key secondary MACE-3 composite endpoint (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) was significantly reduced by 15% compared to placebo (Hazard Ratio: 0.85; 95% CI: 0.76, 0.96; p=0.0058). The primary composite endpoint result was generally consistent across prespecified subgroups (including baseline age, race, ethnicity, sex, LDL-C category, statin use, ezetimibe use, and diabetes). The point estimate for MACE-4 Hazard Ratio was 0.94 (95% CI: 0.74, 1.20) in the subgroup of patients using ezetimibe at baseline. For the limited subgroup of patients with ezetimibe use at baseline and at high cardiovascular risk (n=335), LDL-C reduction was -26.7% (95% CI; -30.9%, -22.4%), but cardiovascular risk reduction could not be estimated.
Impact of bempedoic acid on the individual components of the primary endpoint included a 27% reduction in the risk of non-fatal myocardial infarction and a 19% reduction in the risk of coronary revascularization compared to placebo. There was no statistically significant difference in the reduction of non-fatal stroke and risk of cardiovascular death compared to placebo. The results of the primary and key secondary efficacy endpoints are shown in Table 3. The Kaplan-Meier curve estimates of the cumulative incidence of the MACE-4 primary and the MACE-3 secondary endpoint are shown in Figures 1 and 2 as follows. The cumulative incidence of the MACE-4 primary endpoint is separated by month 6.
Further, the difference between bempedoic acid and placebo in mean percent change in LDL-C from baseline to month 6 was -20% (95% CI: -21%, -19%). (See Table 3 and Figures 1 and 2.)

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Paediatric population: The European Medicines Agency has waived the obligation to submit the results of studies with Nexlizet in all subsets of the paediatric population in the treatment of elevated cholesterol (see Dosage & Administration for information on paediatric use).
Pharmacokinetics: Absorption: Nexlizet: The bioavailability of bempedoic acid/ezetimibe tablets was similar relative to that from the individual tablets, coadministered. C_max values for bempedoic acid and its active metabolite (ESP15228) were similar between formulations, but ezetimibe and ezetimibe glucuronide C_max values were approximately 13% and 22% lower, respectively, for bempedoic acid/ezetimibe relative to the individual tablets, coadministered. Given a similar overall extent of ezetimibe and ezetimibe glucuronide exposure (as measured by AUC), a 22% lower C_max is unlikely to be clinically significant.
No clinically significant pharmacokinetic interaction was seen when ezetimibe was coadministered with bempedoic acid. Total ezetimibe (ezetimibe and its glucuronide form) and ezetimibe glucuronide AUC and C_max increased approximately 1.6- and 1.8-fold, respectively, when a single dose of ezetimibe was taken with steady-state bempedoic acid. This increase is likely due to inhibition of OATP1B1 by bempedoic acid, which results in decreased hepatic uptake and subsequently decreased elimination of ezetimibe-glucuronide. Increases in the AUC and C_max for ezetimibe were less than 20%.
Bempedoic acid: Pharmacokinetic data indicate that bempedoic acid is absorbed with a median time to maximum concentration of 3.5 hours when administered as Nexlizet 180 mg tablets. Bempedoic acid pharmacokinetic parameters are presented as the mean [standard deviation (SD)] unless otherwise specified. Bempedoic acid can be considered a prodrug that is activated intracellularly by ACSVL1 to ETC-1002-CoA. The steady-state C_max and AUC following multiple dose administration in patients with hypercholesterolaemia were 24.8 (6.9) microgram/mL and 348 (120) microgram·h/mL, respectively. Bempedoic acid steady-state pharmacokinetics were generally linear over a range of 120 mg to 220 mg. There were no time-dependent changes in bempedoic acid pharmacokinetics following repeat administration at the recommended dose, and bempedoic acid steady-state was achieved after 7 days. The mean accumulation ratio of bempedoic acid was approximately 2.3-fold.
Ezetimibe: After oral administration, ezetimibe is rapidly absorbed and extensively conjugated to a pharmacologically active phenolic glucuronide (ezetimibe-glucuronide). Mean C_max occur within 1 to 2 hours for ezetimibe-glucuronide and 4 to 12 hours for ezetimibe. The absolute bioavailability of ezetimibe cannot be determined as the compound is virtually insoluble in aqueous media suitable for injection. Ezetimibe undergoes extensive enterohepatic cycling, multiple peaks of ezetimibe can be observed.
Effect of food: After the administration of bempedoic acid/ezetimibe 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 of bempedoic acid and ezetimibe, respectively. Relative to the fasted state, the fed state resulted in 12% and 42% reductions in ezetimibe glucuronide AUC and C_max, respectively. 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 red blood cells.
Ezetimibe: Ezetimibe and ezetimibe-glucuronide are bound 99.7% and 88% to 92% to human plasma proteins, respectively.
Biotransformation: Bempedoic acid: In vitro metabolic interaction studies suggest that bempedoic acid, as well as its active metabolite and glucuronide forms are not metabolised by and do not inhibit or induce cytochrome P450 enzymes.
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.
The steady-state C_max and AUC of the equipotent active metabolite (ESP15228) of bempedoic acid in patients with hypercholesterolaemia were 3.0 (1.4) microgram/mL and 54.1 (26.4) microgram·h/mL, respectively. ESP15228 likely made a minor contribution to the overall clinical activity of bempedoic acid based on systemic exposure and pharmacokinetic properties.
Ezetimibe: In preclinical studies, it has been shown that ezetimibe does not induce cytochrome P450 drug metabolising enzymes. No clinically significant pharmacokinetic interactions have been observed between ezetimibe and drugs known to be metabolised by cytochromes P450 1A2, 2D6, 2C8, 2C9, and 3A4, or N-acetyltransferase. Ezetimibe is metabolised primarily in the small intestine and liver via glucuronide conjugation (a phase II reaction) with subsequent biliary excretion. Minimal oxidative metabolism (a phase I reaction) has been observed in all species evaluated. 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. Both ezetimibe and ezetimibe-glucuronide are slowly eliminated from plasma with evidence of significant enterohepatic recycling.
Elimination: Bempedoic acid: The steady-state clearance (CL/F) of bempedoic acid determined from a population PK analysis in patients with hypercholesterolaemia was 12.1 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 19 (10) hours at steady-state.
Following single oral administration of 240 mg of bempedoic acid (1.3 times the approved recommended dose), 62.1% of the total dose (bempedoic acid and its metabolites) was recovered in urine, primarily as the acyl glucuronide conjugate of bempedoic acid, and 25.4% was recovered in faeces. Less than 5% of the administered dose was excreted as unchanged bempedoic acid in faeces and urine combined.
Ezetimibe: Following oral administration of 14C-ezetimibe (20 mg) to human subjects, total ezetimibe (ezetimibe and ezetimibe-glucuronide) accounted for approximately 93% of the total radioactivity in plasma. Approximately 78% and 11% of the administered radioactivity were recovered in the faeces and urine, respectively, over a 10-day collection period. After 48 hours, there were no detectable levels of radioactivity in the plasma. The half-life for ezetimibe and ezetimibe-glucuronide is approximately 22 hours.
Special populations: Renal impairment: Bempedoic acid: Pharmacokinetics of bempedoic acid was evaluated in a population PK analysis performed on pooled data from all clinical trials (n=2,261) to assess renal function on the steady-state AUC of bempedoic acid and in a single-dose pharmacokinetic study in subjects with varying degrees of renal function. 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% PI: 1.3, 1.4) and 1.9-fold (90% PI: 1.7, 2.0), respectively (see Precautions).
There is limited information in patients with severe renal impairment; in a single dose study, the bempedoic acid AUC was increased by 2.4-fold in patients (n=5) with severe renal impairment (eGFR <30 mL/min/1.73 m²) compared to those with normal renal function. Clinical studies of Nexlizet did not include patients with ESRD on dialysis (see 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 was increased approximately 1.5-fold, compared to healthy subjects (n=9). This result is not considered clinically significant. An additional patient in this study (post-renal transplant and receiving multiple medicinal products, including ciclosporin) had a 12-fold greater exposure to total ezetimibe.
Hepatic impairment: Nexlizet is not recommended in patients with moderate or severe hepatic impairment due to the unknown effects of increased exposure to ezetimibe.
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. 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 was increased approximately 1.7-fold in patients with mild hepatic impairment (Child-Pugh A), compared with healthy subjects. In a 14-day, multiple-dose study (10 mg daily) in patients with moderate hepatic impairment (Child-Pugh B), the mean AUC for total ezetimibe was increased approximately 4-fold on Day 1 and Day 14 compared with healthy subjects.
Other special populations: Bempedoic acid: Of the 3,621 patients treated with bempedoic acid in the placebo-controlled studies, 2,098 (58%) were >65 years old. No overall differences in safety or efficacy were observed between these patients and younger patients.
The pharmacokinetics of bempedoic acid were not affected by age, gender, or race. Body weight was a statistically significant covariate. The lowest quartile of body weight (<73 kg) was associated with an approximate 30% greater exposure. The increase in exposure was not clinically significant and no dose adjustments are recommended based on 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. LDL-C reduction and safety profile are comparable between elderly and young subjects treated with ezetimibe.
Gender: Plasma concentrations for total ezetimibe are slightly higher (approximately 20%) in women than in men. LDL-C reduction and safety profile are comparable between men and women treated with ezetimibe.
Toxicology: Preclinical safety data: Nexlizet: Coadministration of bempedoic acid with doses of ezetimibe in rats at systemic total exposures >50 times the human clinical exposure did not alter the toxicologic profile of either bempedoic acid or ezetimibe. Bempedoic acid in combination with ezetimibe did not alter the effects on embryo-fetal development profile of bempedoic acid or ezetimibe.
Bempedoic acid: The standard battery of genotoxicity studies have not identified any mutagenic or clastogenic potential of bempedoic acid. In full lifetime carcinogenicity studies in rodents, bempedoic acid increased the incidence of hepatocellular and thyroid gland follicular tumours in male rats and hepatocellular tumours in male mice. Because these are common tumours observed in rodent lifetime bioassays and the mechanism for tumourigenesis is secondary to a rodent-specific PPAR alpha activation, these tumours are not considered to translate to human risk.
Increased liver weight and hepatocellular hypertrophy were observed in rats only and were partially reversed after the 1-month recovery at ≥30 mg/kg/day or 4 times the exposure in humans at 180 mg. Reversible, non-adverse changes in laboratory parameters indicative of these hepatic effects, decreases in red blood cell and coagulation parameters, and increases in urea nitrogen and creatinine were observed in both species at tolerated doses. The NOAEL for adverse response in the chronic studies was 10 mg/kg/day and 60 mg/kg/day associated with exposures below and 15 times the human exposure at 180 mg in rats and monkeys, respectively.
Bempedoic acid was not teratogenic or toxic to embryos or foetuses in pregnant rabbits at doses up to 80 mg/kg/day or 12 times the systemic exposure in humans at 180 mg. Pregnant rats given bempedoic acid at 10, 30, and 60 mg/kg/day during organogenesis had decreased numbers of viable foetuses and reduced foetal body weight at ≥30 mg/kg/day or 4 times the systemic exposure in humans at 180 mg. An increased incidence of foetal skeletal findings (bent scapula and ribs) were observed at all doses, at exposures below the systemic exposure in humans at 180 mg. In a pre- and post-natal development study, pregnant rats administered bempedoic acid at 5, 10, 20 and 30 mg/kg/day throughout pregnancy and lactation had adverse maternal effects at ≥20 mg/kg/day and reductions in numbers of live pups and pup survival, pup growth and learning and memory at ≥10 mg/kg/day, with maternal exposures at 10 mg/kg/day, less than the exposure in humans at 180 mg.
Administration of bempedoic acid to male and female rats prior to mating and through gestation day 7 in females resulted in changes in estrous cyclicity, decreased numbers of corpora lutea and implants at ≥30 mg/kg/day with no effects on male or female fertility or sperm parameters at 60 mg/kg/day (4 and 9 times the systemic exposure in humans at 180 mg, respectively).
Ezetimibe: Animal studies on the chronic toxicity of ezetimibe identified no target organs for toxic effects. In dogs treated for four weeks with ezetimibe (≥0.03 mg/kg/day) the cholesterol concentration in the cystic bile was increased by a factor of 2.5 to 3.5. However, in a one-year study in dogs given doses of up to 300 mg/kg/day no increased incidence of cholelithiasis or other hepatobiliary effects were observed. The significance of these data for humans is not known. A lithogenic risk associated with the therapeutic use of ezetimibe cannot be ruled out.
In coadministration studies with ezetimibe and statins the toxic effects observed were essentially those typically associated with statins. Some of the toxic effects were more pronounced than observed during treatment with statins alone. This is attributed to pharmacokinetic and pharmacodynamic interactions in coadministration therapy. Myopathies occurred in rats only after exposure to doses that were several times higher than the human therapeutic dose (approximately 20 times the AUC level for statins and 500 to 2,000 times the AUC level for the active metabolites).
In a series of in vivo and in vitro assays ezetimibe, given alone or coadministered with statins, exhibited no genotoxic potential. Long-term carcinogenicity tests on ezetimibe were negative.
Ezetimibe had no effect on the fertility of male or female rats, nor was it found to be teratogenic in rats or rabbits, nor did it affect prenatal or postnatal development. Ezetimibe crossed the placental barrier in pregnant rats and rabbits given multiple doses of 1,000 mg/kg/day. The coadministration of ezetimibe and statins was not teratogenic in rats. In pregnant rabbits a small number of skeletal deformities (fused thoracic and caudal vertebrae, reduced number of caudal vertebrae) were observed. The coadministration of ezetimibe with lovastatin resulted in embryolethal effects.