Praluent vs. Repatha: Similaries and Differences

Medically reviewed by Mary Choy, PharmD

Praluent (alirocumab) and Repatha (evolocumab) are in the proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitor drug class. The active ingredient in Praluent is alirocumab, and the active ingredient in Repatha is evolocumab.

Both medications are typically given as a subcutaneous (under the skin) injection every two or four weeks. The frequency of injections may vary depending on factors, such as the specific U.S. Food and Drug Administration (FDA)-approved use.

In general, the Food and Drug Administration (FDA) approved these PCSK9 inhibitors to reduce low-density lipoprotein cholesterol (LDL-C) in certain people. In the United States, roughly 86 million adults 20 years or older have total cholesterol (TC) levels higher than 200 milligrams per deciliter (mg/dL). Approximately 7% of children between the ages of 6 and 19 years old also have high TC.

Though these PCSK9 inhibitors sound very similar, each PCSK9 inhibitor has some important differences, such as other FDA-approved uses, age limitations, and dosage forms. Moreover, some side effects are different.

This article will take a deep dive into the differences between Praluent and Repatha.

What Is Praluent?

Praluent is a monoclonal antibody called alirocumab, which is also considered the active ingredient. A monoclonal antibody is a human-made immune (defense) system protein.

In the case of Praluent, this monoclonal antibody is made to bind to proprotein convertase subtilisin kexin type 9 (PCSK9). PCSK9 is also another type of protein—but it's naturally occurring in the body.

The FDA approved Praluent in adults with heart disease to lower the risk of heart attack, stroke, and unstable angina (chest pain) that requires hospitalization. The FDA also approved Praluent to lower LDL "bad" cholesterol in adults who have primary hyperlipidemia (high cholesterol conditions that run in families)—like heterozygous familial hypercholesterolemia (HeFH) and homozygous familial hypercholesterolemia (HoFH).

In HeFH, Praluent is taken along with a healthy diet alone or in combination with other LDL-lowering medications. In HoFH, the FDA only approved Praluent for use in combination with other LDL-lowering medications.

Some examples of other LDL-lowering medications may include statins and Zetia (ezetimibe). So, PCSK9 inhibitors (like Praluent) are not the initial go-to options for most people. Experts typically recommend a statin first. Afterward, if necessary, ezetimibe is the next add-on choice. Finally, if LDL is still high, then experts may consider a PCSK9 inhibitor in people with familial hypercholesterolemia or a very high risk of heart disease.

Praluent is available as a single-use prefilled pen in two different doses: 75 milligrams (mg) and 150 mg. A prefilled pen is a device that is already "prefilled" or filled ahead of time with a specific dose of Praluent. To inject the medicine under your skin, you push a button on the device.

As of early 2024, no other medications contain alirocumab. There are also no interchangeable biosimilars ("generic versions") available for alirocumab.

How It Works

Praluent works by attaching to the PCSK9 protein and preventing PCSK9 from interacting with the low-density lipoprotein (LDL) receptors (binding sites) on liver cells. Without PCSK9 interacting with these LDL binding sites, more LDL binding sites are available to clear out the "bad" cholesterol from the blood.

What Is Repatha?

Repatha is a monoclonal antibody called evolocumab, which is also considered the active ingredient. It works by inhibiting the proprotein convertase subtilisin kexin type 9 (PCSK9) protein. So, Repatha is in the PCSK9 inhibitor drug class.

The FDA approved Repatha in adults with heart disease to decrease the risk of heart attack, stroke, and coronary revascularization. Coronary revascularization is a procedure to restore blood flow in a blocked heart artery.

In general, the FDA also approved Repatha to lower LDL "bad" cholesterol in people 10 and older who have high cholesterol conditions that run in families—like heterozygous familial hypercholesterolemia (HeFH) and homozygous familial hypercholesterolemia (HoFH).

In adults with familial hypercholesterolemia, Repatha is taken along with a healthy diet alone or in combination with other LDL-lowering medications. In children with HeFH, Repatha is taken with a healthy diet and other LDL-lowering medications. As for children with HoFH, the FDA only approved Repatha for use in combination with other LDL-lowering medications.

Some examples of other LDL-lowering therapies may include statins and ezetimibe. So, PCSK9 inhibitors (like Repatha) are not first-line for most people. Experts typically choose a statin first and ezetimibe as the next add-on choice. Then, experts may consider adding a PCSK9 inhibitor to further reduce high LDL levels in people with familial hypercholesterolemia or a very high risk of heart disease.

Repatha is available in three different dosage forms, including a prefilled syringe, a prefilled SureClick® autoinjector, and a Pushtronex® system.

A prefilled syringe is a single-use syringe that's already filled with a specific Repatha dose of 140 mg. The prefilled SureClick® autoinjector is a single-use device that's also already filled with 140 mg of Repatha. Instead of using a plunger like from a prefilled syringe, however, you will push a button for the device to inject the medication under your skin.

The Pushtronex® system is also a device with an injection button, but it requires you to load a cartridge into it. The cartridge has a prefilled Repatha dose of 420 mg, which is three times higher than the other dosage forms.

As of early 2024, Repatha is the only therapy to contain evolocumab. There are no interchangeable biosimilars ("generic versions") available for evolocumab either.

How It Works

Repatha works by attaching to the PCSK9 protein and preventing PCSK9 from interacting with the low-density lipoprotein (LDL) receptors (binding sites) on liver cells. Without PCSK9 interacting with these LDL binding sites, more LDL binding sites are available to clear out the "bad" cholesterol from the blood.

Dosing Guidelines

Because specific dosages may vary per person, use PCSK9 inhibitors according to the healthcare provider's recommendations. The following, however, are some general dosing guidelines.

Praluent:

• Adults with heart disease or primary hyperlipidemia: In general, the starting dosage is either 75 mg every two weeks or 300 mg every four weeks. If necessary, adjust the dosage to 150 mg every two weeks to further lower LDL ("bad" cholesterol) levels.

• Adults with HeFH undergoing an apheresis procedure to remove LDL or adults with HoFH: The recommended dosage is 150 mg every two weeks. Apheresis is a procedure in which blood passes through an instrument that separates unwanted substances or cells, and then the remainder of the blood returns to circulation.

Praluent comes in a 75 mg or 150 mg prefilled pen. So, for 300 mg doses, you will need to use two 150 mg prefilled pens.

Repatha:

• Adults with heart disease or primary hyperlipidemia: The recommended dosage is either 140 mg every two weeks or 420 mg monthly.

• Children 10 and older with HeFH: The recommended dosage is either 140 mg every two weeks or 420 mg monthly.

• Adults and children 10 and older with HoFH: The starting dose is usually 420 mg monthly. If necessary, after 12 weeks, adjust the dosage to 420 mg every two weeks. If you're going through apheresis, you may start at a dosage of 420 mg every two weeks to match the schedule of your procedure.

Repatha is available as a 140 mg prefilled syringe, 140 mg prefilled autoinjector, and a 420 mg Pushtronex® system. So, for 420 mg doses, you will have the option of using three 140 mg prefilled syringes, three 140 mg prefilled autoinjectors, or one 420 mg Pushtronex® system.

Onset to Action

Refer to the following table for information on how quickly Praluent and Repatha work and how long their effects last.

Because PCSK9 inhibitors are proteins, the body will likely get rid of these medications by breaking them down into smaller proteins and their amino acid building blocks.

Side Effects and Precautions

The following table lists some common side effects of Praluent vs Repatha.

A severe side effect of both PCSK9 inhibitors includes the potential for a serious allergic reaction. Symptoms may include breathing problems, itchiness, and rash. Note that the needle cover of the Repatha prefilled syringe and autoinjector also contain latex.

Get medical help immediately if you develop a severe allergic reaction or serious side effects. Call 911 if your symptoms feel life-threatening.

The long-term safety of both PCSK9 inhibitors is currently unknown.

Safely Taking Praluent vs. Repatha

In general, keep the following in mind about PCSK9 inhibitors:

• Wash your hands with soap and water before use.

• Take the PCSK9 inhibitor out of the refrigerator and allow it to warm up at room temperature. For Praluent, this may take 30 to 40 minutes. For Repatha, the prefilled syringe and autoinjector will take 30 minutes, and the Pushtronex® system with the cartridge will take at least 45 minutes.

• Examine the PCSK9 inhibitor, which should be a pale yellow or colorless liquid. If it contains particles or if it has a cloudy or discolored appearance, don't use it. If it's expired, don't use it.

• Don't shake the PCSK9 inhibitor.

• Don't inject the PCSK9 inhibitor in areas that have tenderness, redness, bruising, swelling, scars, stretch marks, or noticeable veins.

• Inject the PCSK9 inhibitor into one of the following body areas—stomach, thigh, or upper arm. Remember to clean the injection site with an alcohol pad and rotate the injection site for each use. If you have to use the same body area, avoid injecting in the exact same spot of the body area two times in a row.

• Appropriately throw away the PCSK9 inhibitor product in a sharps container or another puncture-resistant container.

Praluent:

Praluent is available as a single-use prefilled pen in two different doses: 75 mg and 150 mg. A prefilled pen is a device that is filled ahead of time with a specific dose of Praluent. To inject the medicine under your skin, you push a button on the device.

Repatha:

Repatha is available in three different dosage forms, including a prefilled syringe, a prefilled SureClick® autoinjector, and a Pushtronex® system.

A prefilled syringe is a single-use syringe that's already "prefilled" with a specific Repatha dose of 140 mg. The prefilled SureClick® autoinjector is a single-use device that's also already filled with 140 mg of Repatha. Instead of using a plunger like from a prefilled syringe, however, you will push a button on the autoinjector device to inject the medication under your skin.

The Pushtronex® system is also a device with an injection button but looks different. Instead of being shaped like a pen, it looks like a cube with a door or lid at the top that swings to the side so you can load a cartridge into the cube. The cartridge has a prefilled Repatha dose of 420 mg, which is three times higher than the other Repatha dosage forms.

The Pushtronex® system also has other bells and whistles—like different-colored lights, flashing or solid lights, and beeping noises—that will let you know when the device is ready, when the injection is starting, when the injection is done, and when you've removed the device from your body.

Because specific directions might vary per person and the different dosage forms, use the PCSK9 inhibitor according to the healthcare provider's recommendations. For more detailed instructions, reach out to a healthcare provider.

Potential for Interaction

There is limited information about drug interactions for PCSK9 inhibitors. Though there are drug interaction studies between each PCSK9 inhibitor and statin, the results concluded that the interaction isn't meaningful.

Review of Efficacy

Past studies showed that PCSK9 inhibitors like Praluent and Repatha are effective at significantly lowering LDL ("bad" cholesterol) levels when added to a statin medication. Prior clinical trials also suggested that these PCSK9 inhibitors may lower the risk of heart disease, such as heart attack and stroke.

Which Is Better?

A meta-analysis (a methodical analysis of a collection of studies) reported that PCSK9 inhibitors may decrease the risk of major heart disease-related events, stroke, and a procedure to restore blood flow in a blocked heart artery. Though Repatha had a positive impact on heart attacks, there were no noted effects for Praluent. So, the meta-analysis suggested that Praluent might be less effective than Repatha.

On the other hand, expert guidelines do not favor one PCSK9 inhibitor over the other. These guidelines also didn't mention using both PCSK9 inhibitors together.

When it comes to using PCSK9 inhibitors, experts typically choose either PCSK9 inhibitor as a third-line option on top of a statin and ezetimibe when additional LDL-lowering is necessary for people with familial hypercholesterolemia or a very high risk of heart disease.

As for the better PCSK9 inhibitor to choose, this decision will likely depend on factors, such as cost, insurance coverage, and your preferences.

Diet and Exercise for High Cholesterol

The following are some tips on healthy lifestyle changes, like diet and exercise, for people with high cholesterol.

• Eat healthy: Eat foods that are high in fiber and foods that are low in sodium (salt), added sugars, saturated fats, and trans fats. So, limit fatty meats, cheese, and dairy desserts. Instead, include the following in your diet: lean meat, fruits, vegetables, oatmeal, beans, and low-fat or fat-free dairy products.

• Exercise: Exercising can help reduce your cholesterol levels. Start with taking the stairs instead of the elevator, parking farther away to walk to the store, or doing jumping jacks during commercial breaks. For adults, work toward two and a half hours per week of moderate physical activity—like brisk walking or riding a bicycle. For children and teenagers, aim for one hour of exercise each day.

• Limit alcohol: Drinking too much alcohol may increase your cholesterol and triglyceride (another type of fat) levels.

• Stop smoking: Smoking can raise your risk for heart disease. Quitting can reduce your risk.

Summary

The PCSK9 inhibitor drug class includes Praluent and Repatha. The active ingredient in Praluent is alirocumab, and the active ingredient in Repatha is evolocumab.

In general, the FDA approved these PCSK9 inhibitors to reduce LDL in certain people. In people with heart disease, both PCSK9 inhibitors lower the risk of heart attack and stroke. However, Praluent also decreases the risk of unstable angina that requires hospitalization. Repatha, on the other hand, reduces the risk of coronary revascularization.

FDA also approved both PCSK9 inhibitors for people with primary hyperlipidemia (high cholesterol conditions that run in families), but Repatha can be taken by children who are 10 or older. Praluent is only for adults.

For these primary hyperlipidemia conditions, each PCSK9 inhibitor may also slightly differ in its requirements or options for use—like use alone with dietary changes or in combination with other LDL-lowering medications.

Initially, these PCSK9 inhibitors seem very similar, but each PCSK9 inhibitor has some important differences, such as FDA-approved uses, age limitations, and side effects. Additionally, Repatha has more dosage form options than Praluent (which comes only as a prefilled pen), but the needle covers on two of the Repatha dosage forms contain latex. Reach out to a healthcare provider to know more about the differences between Praluent and Repatha.

Frequently Asked Questions

How do I store Praluent vs. Repatha?

Store both PCSK9 inhibitors in the fridge between 36 and 46 degrees in the original container to protect the products from light.

If necessary, you can store either PCSK9 inhibitor at room temperature (between 68 and 77 degrees) for 30 days. If the product isn't used within 30 days at room temperature, however, you will need to throw it away.

What should I do if my skin becomes red and itchy after an injection of either drug?

Though injection site reactions like redness and itchiness are common, few people have had to stop either PCSK9 inhibitor because of them.

However, contact a healthcare provider if your symptoms feel severe or won't go away. The healthcare provider may recommend as-needed cool compresses, topical steroids, oral (by mouth) steroids, or antihistamines.

Read the original article on Verywell Health.