I think in the original video they were Nexlizet (Ezetimibe + Bempedoic acid) + Repahta (PCSK9i)
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You can get Nexlizet as a generic from India under the name “Brillo EZ”
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That’s interesting. I think it’s still under patent in the US, but maybe going off patent in the next year or two? I guess the concern with sourcing overseas unknown quality control. That said, I think the rapa that I have been prescribed by Dr. Green in the US may be sourced from India.
The Indian generic Nexlizet I started taking a couple months ago is called Bemdac EZ, and it’s made by Zydus. Zydus is a trusted brand as others have had their rapamycin tested for accuracy and came out with good results.
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Are you getting these from the US? I don’t have a sense of how to access these kinds of generics from the US market, or if that’s even allowable.
No, I get it off Indiamart, just like buying Indian generic rapamycin.
OK, thanks. I’ll see what my doctors says. Sometimes they are confined to whatever is on their med list (e.g. statins only).
In general, these other agents are for patients who do not have adequate results on a statin (e.g. add additional agents) or who have intolerance to statins. They are not currently first choices.
Each agent has its own risk/benefit/costs.
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Hi Dr. Fraser,
Thanks for the comment. I have seen these meds described as statin alternatives / supplements as well. But, it’s not as clear to me that they should be. Peter Attia, in the initial video I posted, speaks to why he is taking these over statins, for example. With doctors or insurance companies, there is often a concern that their own financial incentives, contracts, or economics are in part driving these prescription decisions rather than the best possible medicine for the patient. I’m certainly open to statins, but if there are better alternatives, that would be appealing.
N
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Sun Pharma is one of the largest manufacturers of generics in the world, so I’m thinking it’s probably fine.
As to BA vs. statins, I think it is better targeted at the liver than systemic function of statins.
The only reason it’s not first line is likely just cost.
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That and the fact that statins easily suppress over 2x as much LDL-C and also lower inflammation markers.
According to this page (https://www.pharmacompass.com/patent-expiry-expiration/bempedoic-acid), the US patent seems to have expired last week. I assume probably more complicated than that, but hopefully there will be more generics soon.
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Attia in his video seems to value the idea that BA is more targeted to the live. I don’t really have the experience to validate that preference.
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In terms of statins being more powerful, that might be a disincentive for me. I’ve been on a rigorous diet for a while and have gotten my ApoB into the low 70s. So, I may not need a big medication assist to get into the optimal range (e.g. 50 or below according to Attia and others like Dr. Brad Stanfield). At least I may want to try a less powerful med first to see if I can make it to the goal that way.
The goal is a decent Apolipoprotein B (APO B). Many people will not achieve this without medication. Most people can achieve this with statins and nothing else, without adverse effects. The discontinuation rates are only a small amount due to side effects, and more so from people just not feeling there is a reason to worry about their lipids (until they have an outcome and often irreversible conditions from their neglect). I treat multiple cases per day of such individuals when I work in the ER.
As an anti-aging and regenerative medicine specialist, my very top thing when I see a patient is making sure their vascular risk is solidly addressed, which is multi-pronged, and not just lipids.
It will be the condition that kills or causes disability more people on this board than any other single condition. So it is critically important to get it right.
We need to appreciate the years where you are exposed to high lipids causes cumulative damage, and it takes years to stabilize and hopefully reverse.
For most patients statins are first line, as they are generally well tolerated (and I know there are individuals with side effects and for those we use other things), cheap, and have a solid evidence base. They also work well and achieve targets in most patients. Ezetimibe is also a reasonable and cheap add-on when needed. At times, and for patients with Lp(a) or familial hyperlipidemia the PCSK9 inhibitors and Bempedoic acid come into play.
Dr. Attia has his opinion, and likely has reasons for it; but if he is taking non-statin medications first and would prescribe those first to a patient instead of first trialing a statin, he would be practicing in a way contrary to what current lipidologists and cardiologist recommend based on strong evidence. I suspect there is some nuance there in his situation as he is a smart fellow for sure.
In general, I’d not be jumping to them first due to cost and side effect profile respectively.
This is not meant to provide any specific medical advice for a specific individual, but is just to contextualize how most up to date physicians contextualize this topic.
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Thanks Dr. F. I do get the sense that there is an anti-statin bias in some areas that may not be based in science / rationality. I guess an interesting question is whether the newer drugs would be more prescribed if the pricing were similar.
Attia is up with a new video today that, coincidentally, focuses on these issues, here:
Discussion of statins and alternatives starts at 56:52, although there is a lot on ApoB, LDL, etc. before that.
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Lmao the discussion on berberine was weird around 1:34:00. 
Rhonda is all like I have this meta analysis, it looks good. Then Peter just randomly says it’s interesting since it’s a mitochondrial toxin and she is completely caught off guard. It ends up with her just saying she has ordered it and will try it and they don’t address the mitochondrial toxin issue, looks like Rhonda hoped Peter would intervene.
I had weird pain in my hands and in my toe from berberine, very dirty drug, it did decrease my apoB though.
@DrFraser I am statin intolerant (at least for Rosuvastatin) and I am currently taking Bempedoic Acid. I haven’t gotten my bloodwork done yet because I want to trial BA for 3 months to get a feel for how it is affecting my LDL and ApoB. Do you think there is a great benefit to trialing a different statin over BA? Cost is not a factor for me as BA is as cheap as statins when bought from India. Thank you.
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I won’t give anyone personalized medical advice on this forum, but I can give some general context and information.
In general when I start people on statins, I utilize Atorvastatin most times, and go with 10 mg every other day, and if tolerated x 2 weeks then either go to daily or 20 mg every other day. Many who have intolerance do better with alternate day dosing.
Much of the benefit of most drugs occurs at their lower range of dosing, and as we push doses up the benefits are smaller and risk of side effects go up. I personally do 20 mg of Atorvastatin every other day and 5 mg of Ezetimibe daily. There is a nice trial showing 5 mg of ezetimibe essentially gets same result as 10 mg.
With using 2 agents in super low doses, unlikely to cause side effects in most people, ApoB drop by 40 pts in me.
Cheap, easy, well tolerated by most people.
I take the same approach with blood pressure, with many of my patients on 4 meds, but tiny doses, way better tolerated and more effective than 2 meds pushed to maximum doses which generally results in a high frequency of side effects.
I’d not going to other agents as first line therapy for my patients.
Your situation might differ, but hopefully this general context of how I approach this topic with my patients is helpful.
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Thanks. I originally tried Rosuvastatin at 5 mg every other day and the muscle soreness was unbearable. That’s why I took Dr. Attias advice and tried Bempedoic Acid which hasn’t caused any side effects. Ezetemibe at 10 mg actually had positive side effects (energy boost). I guess I’ll just wait for the next blood work results and then go from there. Sometimes you just need the hard data to see what’s happening.
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