Bempedoic Acid Gout Risk Calculator
How to Use This Tool
This calculator estimates your risk of developing gout while taking bempedoic acid based on your uric acid levels and medical history. Based on clinical study data, 1.5% of users develop gout for the first time, and risk increases for those with prior gout history.
When you can’t take statins because of muscle pain or weakness, bempedoic acid (sold as Nexletol) might seem like a lifesaver. It lowers LDL cholesterol without hitting your muscles the same way statins do. But it doesn’t come without its own risks. Gout flares, tendon tears, and liver changes are real concerns - and they’re not rare. If you’re considering this drug or already taking it, here’s what actually happens in your body - and what you should watch for.
How Bempedoic Acid Works (And Why It’s Different From Statins)
Bempedoic acid blocks an enzyme called ATP-citrate lyase in the liver. That’s the same spot where cholesterol gets made. By slowing that down, your liver pulls more LDL cholesterol out of your blood. It’s a smart workaround: it doesn’t enter muscle tissue like statins do, which is why muscle pain is much less common. In clinical trials, only about 5.8% of people on bempedoic acid had muscle spasms, compared to 10-15% on statins. That’s a big win for people who had to quit statins because their legs hurt or they couldn’t walk without cramps.
But here’s the catch: blocking cholesterol production in the liver doesn’t just affect cholesterol. It also changes how your body handles uric acid - a waste product that, when it builds up, turns into sharp crystals in your joints. That’s where gout comes in.
Gout: The Most Common Serious Side Effect
One in 67 people taking bempedoic acid will have a gout attack. That’s 1.5% - more than triple the rate in people taking a placebo. For someone who already had gout before starting the drug, the risk jumps to 2.3%. That’s not a small number. The first flare often hits within the first four weeks. You’ll feel it: sudden, intense pain in your big toe, ankle, or knee. The joint swells, turns red, and feels hot to the touch. It’s not just uncomfortable - it can sideline you for days.
Why does this happen? Bempedoic acid reduces uric acid clearance in the kidneys. Your body holds onto more of it, and when levels rise above 6.8 mg/dL, crystals form. The FDA requires doctors to check your uric acid levels before you start and again at four weeks. If it’s climbing, you might need allopurinol - a drug that helps your body get rid of uric acid. Studies show this cuts gout risk by 65% in people on bempedoic acid. Don’t wait for a flare to ask about it.
Tendon Rupture: A Silent but Dangerous Risk
While gout is painful, tendon rupture is scary. You might not feel anything until it’s too late. A sudden pop in your Achilles tendon. Inability to push off your foot. Bruising that appears without injury. These aren’t just side effects - they’re medical emergencies.
In clinical trials, 0.7% of people on bempedoic acid had tendon problems. That’s seven out of every 1,000. For comparison, statins cause tendon issues in about 0.1-0.3% of users. The risk skyrockets when you combine bempedoic acid with statins. One study found the chance of tendon rupture was 3.5 times higher in people taking both. The FDA and European Atherosclerosis Society warn against using bempedoic acid if you’re already on fluoroquinolone antibiotics (like ciprofloxacin or levofloxacin). Both drugs weaken tendons. Together, they’re a recipe for disaster.
There’s no warning before it happens. No tingling, no ache. Just a snap - and then you’re down. If you feel any new stiffness, pain, or swelling in your heels, shoulders, or hands, stop taking it and call your doctor immediately. Don’t wait for it to get worse.
Other Side Effects You Can’t Ignore
Beyond gout and tendons, bempedoic acid has a handful of other red flags:
- Liver enzymes: 2.2% of users see ALT or AST levels rise above normal. In 1.6%, they go over three times the upper limit. Your doctor should check your liver function every three months, especially in the first year.
- Anemia: Hemoglobin drops slightly in about 1.8% of people. It’s usually mild - less than 1 g/dL - and rarely needs treatment. But if you’re feeling unusually tired or short of breath, get a blood test.
- Upper respiratory infections: Colds and bronchitis are more common. About 7.7% of users get them, compared to 5.1% on placebo. It’s not clear why, but it’s consistent across trials.
- Abdominal pain and diarrhea: Around 3% of people report stomach discomfort. It’s usually mild and fades after a few weeks.
Some side effects - like muscle spasms and back pain - are common but not dangerous. They happen in 5-6% of users and often go away on their own. Only 1.2% of people stop taking the drug because of them.
Who Should Avoid Bempedoic Acid Altogether?
This isn’t for everyone. Avoid it if you:
- Have a history of gout or high uric acid levels (unless you’re on preventive treatment like allopurinol)
- Have had a tendon rupture before
- Are taking fluoroquinolone antibiotics
- Have active liver disease or unexplained liver enzyme elevations
- Are pregnant or breastfeeding
The European Atherosclerosis Society says if you’ve had tendon problems in the past - even mild ones - you should skip this drug. The risk isn’t worth it.
What About Long-Term Safety?
The CLEAR Outcomes trial, published in 2023, followed over 14,000 people for nearly four years. Those taking bempedoic acid had 13% fewer heart attacks, strokes, and deaths from heart disease compared to placebo. That’s powerful. For people who can’t take statins, this drug saves lives.
But safety isn’t just about heart events. It’s about what else happens along the way. The same trial showed that gout and tendon injuries remained elevated throughout the study period. There’s no sign the body adapts. The risk doesn’t fade after six months. That means if you’re on this drug long-term, you need ongoing monitoring - not just for cholesterol, but for uric acid, liver function, and tendon health.
How to Stay Safe on Bempedoic Acid
If your doctor says you’re a good candidate, here’s how to protect yourself:
- Get a baseline uric acid test before starting. Know your number.
- Ask about allopurinol if your uric acid is above 6.5 mg/dL. Don’t wait for a flare.
- Check liver enzymes at 4 weeks, then every 3 months.
- Don’t combine with statins unless absolutely necessary. If you do, monitor tendons extra closely.
- Avoid fluoroquinolones like ciprofloxacin. If you need an antibiotic, ask for something else.
- Report any tendon pain immediately. Don’t tough it out.
- Stay active, but avoid sudden, high-impact movements. Gradual strengthening helps protect tendons.
Most people tolerate bempedoic acid fine. But for the ones who don’t - the ones who get gout or a torn tendon - the consequences can be life-changing. That’s why knowing the signs matters more than the numbers on a lab report.
Is It Worth It?
Bempedoic acid isn’t a miracle drug. It’s a tool - one with sharp edges. If you’re statin-intolerant and your LDL is still above 100 mg/dL despite diet and ezetimibe, then yes, it’s worth considering. The cardiovascular benefits are real. But if you’re already managing your cholesterol well with other methods, or if you have a history of gout or tendon problems, the risks may outweigh the rewards.
It’s not about choosing between bad and good. It’s about choosing the least bad option for your body. Talk to your doctor about your personal risk factors. Ask for your uric acid numbers. Ask about tendon safety. Don’t assume it’s safe just because it’s not a statin. It’s different - and that difference comes with its own set of dangers.
Can bempedoic acid cause gout even if I’ve never had it before?
Yes. About 1.5% of people who take bempedoic acid develop gout for the first time, even if they’ve never had it before. The drug raises uric acid levels in the blood, which can lead to crystal formation in joints. Most first-time gout attacks happen within the first four weeks of starting the medication.
How do I know if I’m at risk for tendon rupture?
You’re at higher risk if you’ve had tendon problems before, are over 60, take corticosteroids, or are on fluoroquinolone antibiotics. The risk also increases if you take bempedoic acid with a statin. If you suddenly feel a pop, sharp pain, or swelling in your Achilles, shoulder, or hand tendon - stop the drug and get medical help right away.
Does bempedoic acid damage the liver?
It can raise liver enzyme levels in about 2.2% of users, and in 1.6% of cases, the increase is more than three times the normal limit. This doesn’t always mean liver damage, but it does mean you need regular blood tests. If enzymes keep rising, your doctor may stop the drug. Most cases are mild and reversible when the medication is paused.
Can I take bempedoic acid with ezetimibe?
Yes. In fact, the combination is sold as Nexlizet and is FDA-approved for patients who need stronger LDL lowering. The side effect profile is similar to bempedoic acid alone - gout and tendon risks remain, but ezetimibe doesn’t add new safety concerns. Many doctors prefer this combo because it’s more effective than either drug alone.
Are there alternatives to bempedoic acid if I can’t take statins?
Yes. Ezetimibe is the first-line alternative - it’s safer for tendons and doesn’t raise uric acid. PCSK9 inhibitors like evolocumab or alirocumab are injectable options with strong heart benefits and very low side effect rates. For some, lifestyle changes and high-dose fish oil may help. The best choice depends on your cholesterol levels, heart disease risk, and personal health history.
Next steps: If you’re on bempedoic acid, schedule a uric acid test if you haven’t had one in the last 30 days. If you’re considering it, ask your doctor for your current LDL and uric acid numbers - and discuss whether the heart benefits outweigh your personal risk for gout or tendon issues. This isn’t a one-size-fits-all drug. Your body’s response matters more than the label.