SJ is a 54-year-old female that presents to your pharmacy with a new prescription for Repatha 140mg/mL SureClick autoinjector.

Past Medical History: Heterozygous familial hyperlipidemia, Type 2 diabetes mellitus, Depression

Medications: Multivitamin, escitalopram 10mg QD, metformin 1000mg BID, atorvastatin 40mg daily

While your team prepares the prescription for dispensing you begin thinking about your counseling points. Which of the following are appropriate counseling points for SJ regarding Repatha? Select all that apply.

A. Repatha is a PCSK9 inhibitor that helps to lower LDL in patients with hyperlipidemia.

B. Repatha when given with escitalopram may increase risk of QTc prolongation.

C. Repatha is given 140mg subcutaneously every 2 weeks or 420mg subcutaneously monthly.

D. Repatha should be avoided with HMG CoA reductase inhibitors due to increased risk of myopathy.

E. Patients with a documented latex allergy should use caution when taking Repatha.

Brand/Generic: Evolocumab (Repatha); Escitalopram (Lexapro); Metformin (Glucophage), Atorvastatin (Lipitor)

Repatha is a PCSK9 inhibitor which improves LDL in patients with dyslipidemia. It works by inhibiting PCSK9, improving the level of LDL receptors and the subsequent uptake of LDL from the blood. This is important because it improves cardiovascular health of patients and has the potential to prevent major cardiovascular events like heart attack or stroke. It can be used in patients with cardiovascular disease, primary hyperlipidemia, heterozygous familial hypercholesteremia, or in adjunct with other LDL-lowering therapies for patients with homozygous familial hypercholesteremia. Repatha is a once or twice monthly subcutaneous injection depending on the dose and comes as an autoinjector or prefilled syringe. 

Choice A is correct as this is the correct mechanism of action and indication for Repatha. PCSK9 in the body degrades LDL receptors. By inhibiting PCSK9, there is an increase in LDL receptors and a subsequent increase in LDL removal from the blood. Repatha can be used for patients with cardiovascular disease, primary hyperlipidemia, heterozygous familial hypercholesteremia, or homozygous familial hypercholesteremia. Because this patient has primary hyperlipidemia, Repatha would be indicated for this patient. Alirocumab (Praluent) is another FDA-approved PCSK9 inhibitor. Inclisiran (Leqvio) is a small interfering mRNA molecule that inhibits the synthesis of PCSK9. 

Choice B is incorrect because Repatha does not increase risk of QTc prolongation. Escitalopram itself can increase risk of QTc prolongation as well as citalopram so careful monitoring of any drugs that would interact is prudent. 

Choice C is correct as this is a typical dose of Repatha. Repatha can be given as a 140mg injection once every 2 weeks or as a 420mg injection once every month.

Choice D is incorrect because Repatha is commonly given and FDA-approved with statins or other agents to further decrease LDL and decrease risk of cardiovascular events such as MI or stroke. There is no additive risk of myopathy using statins and PCSK9 inhibitors together. Our patient has heterozygous familial hypercholesterolemia which is known to have significant elevations in LDL requiring multiple agents. Repatha may in some occasions be used in patients who are statin intolerant due to musculoskeletal side effects experienced while on a statin. 

Choice E is correct as this is another important counseling point for patients. The needle cover of the Repatha prefilled syringe and autoinjector both contain dry natural rubber which is a derivative of latex. This can cause an allergic reaction in patients that have a latex allergy. 

The correct answers are A, C, and E.

NAPLEX Competencies Covered:

Area 1: Obtain, Interpret, or Assess Data, Medical, or Patient Information

1.3 From practitioners: treatment adherence, or medication-taking behavior; chief complaint, medication history, medical history, family history, social history, lifestyle habits, socioeconomic background

Area 2: Identify Drug Characteristics 

2.1 Pharmacology, mechanism of action, or therapeutic class

2.2 Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar names; physical descriptions; or how supplied 

Area 3: Develop or Manage Treatment Plans 

3.2 Therapeutic goals or outcomes and clinical endpoints

3.3 Medication reconciliation; indication or therapeutic uses; lack of indication; inappropriate indication; duplication of therapy; omissions

3.4 Drug dosing or dosing adjustments; duration of therapy

3.5 Drug route of administration, dosage forms, or delivery systems

3.6 Drug contraindications, allergies, or precautions

3.7 Adverse drug effects, toxicology, or overdose

Area 5: Compound, Dispense, or Administer Drugs, or Manage Delivery Systems

5.5 Instructions or techniques for drug administration 

Resources:

Repatha Package Insert

https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/125522orig2s000lbl.pdf

See everyone next week! 

Dr. B