Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution Auto-injector, Subcutaneous [preservative free]:
Repatha SureClick: 140 mg/mL (1 mL) [contains mouse (murine) and/or hamster protein, polysorbate 80]
Solution Cartridge, Subcutaneous [preservative free]:
Repatha Pushtronex System: 420 mg/3.5 mL (3.5 mL) [contains polysorbate 80]
Solution Prefilled Syringe, Subcutaneous [preservative free]:
Repatha: 140 mg/mL (1 mL) [contains mouse (murine) and/or hamster protein, polysorbate 80]
Pharmacology
Mechanism of Action
Evolocumab is a human monoclonal antibody (IgG2 isotype) that binds to proprotein convertase subtilisin kexin type 9 (PCSK9). PCSK9 binds to the low-density lipoprotein receptors (LDLR) on hepatocyte surfaces to promote LDLR degradation within the liver. LDLR is the primary receptor that clears circulating LDL; therefore, the decrease in LDLR levels by PCSK9 results in higher blood levels of LDL-cholesterol (LDL-C). By inhibiting the binding of PCSK9 to LDLR, evolocumab increases the number of LDLRs available to clear LDL from the blood, thereby lowering LDL-C levels.
Pharmacokinetics/Pharmacodynamics
Distribution
IV: Vd: ~3.3 L
Metabolism
Nonsaturable proteolysis
Onset of Action
Peak effect: Proprotein convertase subtilisin kexin type 9 (PCSK9) suppression: 4 hours
Time to Peak
SubQ: 3 to 4 days
Half-Life Elimination
11 to 17 days
Use in Specific Populations
Special Populations: Hepatic Function Impairment
In patients with mild or moderate hepatic impairment, a 20% to 30% lower mean Cmax and 40% to 50% lower mean AUC occurs.
Use: Labeled Indications
Homozygous familial hypercholesterolemia: Adjunct to diet and other LDL-lowering therapies (eg, statins, ezetimibe, LDL apheresis) for the treatment of patients with homozygous familial hypercholesterolemia who require additional lowering of LDL-C
Hyperlipidemia, primary: Adjunct to diet, alone or in combination with other lipid-lowering therapies (eg, maximum tolerated dose of statins), for the treatment of adults with primary hyperlipidemia, including heterozygous familial hyperlipidemia, to reduce LDL-C (Sabatine 2015)
Prevention of cardiovascular events in patients with established cardiovascular disease: To reduce the risk of MI, stroke, and coronary revascularization in adults with established cardiovascular disease. Note: Use in combination with an optimized regimen of lipid-lowering therapy (eg, high-intensity statin) (Sabatine 2017).
Contraindications
Serious hypersensitivity to evolocumab or any component of the formulation.
Documentation of allergenic cross-reactivity for PCSK9 inhibitors is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.
Dosage and Administration
Dosing: Adult
Note: Use may be considered in patients who do not meet cholesterol treatment goals with dietary modification and other lipid-lowering therapies (eg, maximally tolerated statin with or without ezetimibe) (AHA/ACC [Grundy 2018]).
Homozygous familial hypercholesterolemia: SubQ: 420 mg once monthly.
Off-label dosing: 420 mg once every 2 weeks (after 12 weeks, may decrease to 420 mg once a month) in conjunction with lipid apheresis has been studied in a limited number of patients (Bruckert 2014). The European Atherosclerosis Society recommends administration directly after lipid apheresis (EAS [France 2016]).
Hyperlipidemia, primary: SubQ: 140 mg every 2 weeks or 420 mg once monthly.
Prevention of cardiovascular events in patients with established cardiovascular disease: SubQ: 140 mg every 2 weeks or 420 mg once monthly.
Switching regimens: Administer the first dose of the new regimen on the next scheduled day of the prior regimen.
Missed dose: Administer within 7 days from the missed dose and resume original schedule. If an every-2-week dose is not administered within 7 days, wait until the next dose on the original schedule. If a once-monthly dose is not administered within 7 days, administer the dose and start a new schedule based on this date.
Dosing: Geriatric
Refer to adult dosing.
Dosing: Pediatric
Homozygous familial hypercholesterolemia: Adolescents 13 to 17 years: SubQ: Refer to adult dosing.
Missed dose: Refer to adult dosing.
Administration
For SubQ administration. Do not shake. If refrigerated, allow to stand at room temperature for at least 30 minutes (single-use prefilled autoinjector or single-use prefilled syringe) or at least 45 minutes (single-use on-body infusor with prefilled cartridge) prior to use (do not warm with heat or hot water). Administer into areas of the abdomen (except for the 2-inch area around the navel), thigh, or upper arm; only use areas that are not tender, bruised, red, or indurated. Do not coadminister with other injectable drugs at the same injection site. Rotate the injection site with each injection.
Once-monthly dose (ie, 420 mg): Administer SubQ over 9 minutes using the single-use infusor with prefilled cartridge or give 3 separate SubQ 140 mg injections consecutively within a 30-minute period using the single-use prefilled autoinjector or single-use prefilled syringe.
Storage
Store between 2°C to 8°C (36°F to 46°F) in the original carton. May also store at room temperature (at 20°C to 25°C [68°F to 77°F]) in the original carton; however, under these conditions, must use within 30 days (discard if not used within 30 days). Protect from direct light and do not expose to temperatures above 25°C (77°F). Do not freeze.
Drug Interactions
There are no known significant interactions.
Adverse Reactions
>10%: Respiratory: Nasopharyngitis (6% to 11%)
1% to 10%:
Cardiovascular: Hypertension (3%)
Central nervous system: Dizziness (4%), fatigue (2%)
Dermatologic: Skin rash (1%)
Endocrine & metabolic: Diabetes mellitus (9%)
Gastrointestinal: Gastroenteritis (3% to 6%), nausea (2%)
Genitourinary: Urinary tract infection (5%)
Hematologic & oncologic: Bruise (1%)
Infection: Influenza (8% to 9%)
Local: Injection site reaction (6%)
Neuromuscular & skeletal: Myalgia (4%)
Respiratory: Upper respiratory tract infection (9%), cough (1% to 5%), sinusitis (4%)
<1%, postmarketing, and/or case reports: Angioedema, antibody development, flu-like symptoms, hypersensitivity reaction
Warnings/Precautions
Concerns related to adverse effects:
- Hypersensitivity reactions: Hypersensitivity reactions (eg, angioedema, rash, urticaria) have been reported, some requiring discontinuation. Discontinue treatment and initiate supportive treatment in patients who develop signs/symptoms of serious allergic reaction; monitor until symptoms resolve.
Concurrent drug therapy issues:
- Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
Dosage form specific issues:
- Latex: The packaging (needle cap of prefilled syringe and autoinjector) may contain dry natural rubber, which is a derivative of latex.
Monitoring Parameters
Lipid profile (fasting or nonfasting) before initiating treatment; fasting lipid profile should be rechecked 4 to 12 weeks after starting therapy and every 3 to 12 months thereafter (AHA/ACC [Grundy 2018]); signs/symptoms of hypersensitivity reactions.
Pregnancy
Pregnancy Considerations
Evolocumab is a humanized monoclonal antibody (IgG2). Potential placental transfer of human IgG is dependent upon the IgG subclass and gestational age, generally increasing as pregnancy progresses. The lowest exposure would be expected during the period of organogenesis (Palmeira 2012; Pentsuk 2009).
Data collection to monitor pregnancy and infant outcomes following exposure to evolocumab is ongoing. Health care providers are encouraged to enroll females exposed to evolocumab during pregnancy in the Pregnancy Registry (1-877-311-8972 or https://mothertobaby.org/ongoing-study/repatha).
Patient Education
What is this drug used for?
- It is used to lower cholesterol.
- It is used in some people to lower the chance of heart attack, stroke, and certain heart procedures.
Frequently reported side effects of this drug
- Sore throat
- Stuffy nose
- Flu-like symptoms
- Common cold
- Back pain
- Injection site irritation
Other side effects of this drug: Talk with your doctor right away if you have any of these signs of:
- High blood sugar like confusion, fatigue, increased thirst, increased hunger, passing a lot of urine, flushing, fast breathing, or breath that smells like fruit
- Signs of a significant reaction like wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat.
Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.
Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.
