CardiologyPublished: October 2026·Updated: October 2026·9 min read

Bempedoic Acid and Tendon Rupture: Is the Risk Real?

Bempedoic acid tendon rupture is the side effect that worries patients most when we suggest this cholesterol tablet in our Singapore clinic, usually because they have read the label: tendon rupture in 0.5% of people taking it, and 0% on placebo. That sounds alarming. The fuller picture is more reassuring. The 0.5% comes from early trials of a few thousand patients. The far larger CLEAR Outcomes trial, which followed nearly 14,000 people for over three years, found ruptures in 1.2% on bempedoic acid and 0.9% on placebo, a small difference that did not reach statistical significance. Here is what we know about how it might happen, which tendons are involved, and how we decide who should avoid it.

Dr. Peter Chang

Triple Board-Certified Cardiologist & Vascular Specialist

Is the Bempedoic Acid Tendon Rupture Risk Real?

Probably, but it is small, and smaller than the headline figure suggests. Bempedoic acid lowers LDL cholesterol by blocking an enzyme called ATP citrate lyase in the liver, upstream of where statins act. In Singapore, as elsewhere, it is mainly used for people who cannot tolerate statins.

The tendon warning comes from the four phase 3 CLEAR trials, where tendon rupture occurred in 0.5% of patients on bempedoic acid and none on placebo. With so few events, a zero in the placebo group makes any difference look dramatic.

CLEAR Outcomes was designed to settle questions like this. Among 13,970 statin-intolerant patients followed for a median of about 40 months, adjudicated tendon rupture occurred in 1.2% versus 0.9%, and tendinopathy overall in 2% of both groups (NEJM, 2023). That works out to roughly one extra rupture for every 300 or so patients treated for three years, if the difference is real at all.

Which Tendons Rupture With Bempedoic Acid?

The label lists three: the rotator cuff in the shoulder, the biceps tendon, and the Achilles tendon at the back of the ankle. Ruptures occurred within weeks to months of starting treatment.

That list is telling. These are exactly the tendons that rupture most often in anyone over 60, with or without medication. Each has a relatively poor blood supply in a short segment, carries heavy repetitive loads, and degenerates quietly with age. Rotator cuff tears in particular are so common in older adults that many are found by chance on shoulder scans in people with no symptoms.

So a trial population of older, often diabetic patients with heart disease, which describes most people prescribed bempedoic acid in Singapore and elsewhere, will produce tendon ruptures whatever they take. The question is only whether bempedoic acid adds to that background rate.

How Could Bempedoic Acid Cause Tendon Rupture?

The honest answer is that no one knows. There is no established mechanism, and anyone who tells you otherwise is guessing with confidence. It is still the question our Singapore patients ask most, so here are the candidate explanations, from most to least likely in our view:

Chance: with only a handful of events in the early trials, a zero in the placebo arm can arise from random variation alone
Uric acid: bempedoic acid raises urate by competing for kidney transporters, and urate crystals can deposit in and weaken tendons, though this has not been shown to explain the ruptures
Tendon cell metabolism: blocking ATP citrate lyase alters how cells handle acetyl-CoA, a building block for fats and other molecules, and tendon cells may be sensitive to this, though the drug is activated mainly in the liver
Shared risk factors: the patients most likely to receive bempedoic acid are older, have diabetes or kidney disease, and may take steroids, all of which independently weaken tendons

Bempedoic Acid Tendon Pain: The Warning Signs

A tendon rarely snaps without warning. In the weeks before a rupture, there is often tendinopathy: pain, stiffness and swelling over the tendon, worst first thing in the morning or at the start of activity. If you are taking bempedoic acid, these deserve a call to your doctor rather than a stoic shrug, which we see a great deal of in Singapore.

The label advice is clear: stop the medicine at the first sign of tendon rupture and seek prompt assessment. Ultrasound or MRI confirms the diagnosis, and early repair gives the best result for Achilles and rotator cuff injuries.

Achilles: a sensation of being kicked in the heel, a pop, then difficulty pushing off or standing on tiptoe
Rotator cuff: sudden shoulder pain and weakness lifting the arm, especially overhead
Biceps: a pop at the front of the shoulder or elbow, bruising, and a bulge in the upper arm sometimes called a Popeye sign

Who Should Be Careful With Bempedoic Acid?

The FDA prescribing information identifies groups in whom tendon rupture may occur more often. In these patients, we weigh the benefits more carefully and sometimes choose ezetimibe or a PCSK9 therapy instead. In Singapore, the fluoroquinolone point matters: ciprofloxacin and levofloxacin are common prescriptions for urinary and chest infections, and they carry their own tendon warning.

People over 60
Anyone taking corticosteroids such as prednisolone, including repeated steroid injections
Anyone taking fluoroquinolone antibiotics, even briefly
People with kidney failure or a previous tendon disorder or rupture
People with gout, as bempedoic acid also raises uric acid

Weighing the Risk Against the Benefit

Every cholesterol medicine is a trade. In CLEAR Outcomes, bempedoic acid lowered LDL cholesterol by about 21% compared with placebo and reduced major cardiovascular events by 13%, including fewer heart attacks and coronary procedures. For a statin-intolerant patient with established heart disease, that benefit is substantial.

The trial also showed the other trade-offs worth knowing: gout in 3.1% versus 2.1% and gallstones in 2.2% versus 1.2%. Unlike statins, bempedoic acid is activated mainly in the liver, not muscle, which is why muscle aches were no more common than with placebo.

In our practice in Singapore, we usually prefer a well-tolerated statin first. When statins truly fail, bempedoic acid is a sensible option, provided we have screened for the tendon and gout risk factors above.

Talking It Through With a Specialist in Singapore

If you are taking bempedoic acid and have tendon pain, do not simply stop all your cholesterol treatment indefinitely; pause the bempedoic acid and arrange a review promptly. If you have a sudden pop or cannot bear weight, go to an emergency department.

For patients weighing up statin alternatives, a review at Paragon Medical Centre on Orchard Road typically costs SGD 150 to SGD 350 for a first consultation, with lipid blood tests adding a modest amount. Bring a list of every medicine, including recent antibiotics and steroid injections, your past cholesterol results, and any history of gout or tendon injury. That short list usually decides whether bempedoic acid tendon rupture is a theoretical worry or a practical reason to choose something else.

Frequently Asked Questions

Common Questions About Bempedoic Acid and Tendon Rupture

How common is tendon rupture with bempedoic acid?

In the early phase 3 trials, tendon rupture occurred in 0.5% of patients on bempedoic acid and none on placebo. In the much larger CLEAR Outcomes trial of nearly 14,000 patients followed for over three years, the figures were 1.2% versus 0.9%, a difference that was not statistically significant. The true extra risk, if any, is probably a fraction of one percent.

Which tendons are affected by bempedoic acid?

The reported ruptures involved the rotator cuff in the shoulder, the biceps tendon and the Achilles tendon. These are also the tendons that rupture most often in people over 60 regardless of medication, because they carry heavy loads, have areas of poor blood supply and degenerate with age.

Should I stop bempedoic acid if my tendon hurts?

Yes, pause it and contact your doctor promptly. Pain, swelling or stiffness over a tendon can precede a rupture. Stopping is easy to reverse, while a ruptured Achilles or rotator cuff can take months to recover. Do not stop all cholesterol treatment indefinitely, though; your doctor can switch you to an alternative such as ezetimibe or a PCSK9 therapy.

Is bempedoic acid safe for people over 60?

For most people over 60, yes, but age is one of the listed risk factors for tendon rupture, so we check for the others before prescribing: steroid use, recent fluoroquinolone antibiotics, kidney disease, gout and previous tendon problems. If several apply, we usually choose a different cholesterol medicine.

Can I take bempedoic acid with antibiotics in Singapore?

Most antibiotics are fine. The concern is fluoroquinolones such as ciprofloxacin and levofloxacin, which are commonly prescribed in Singapore for urinary and chest infections and carry their own tendon rupture warning. If you are offered one, tell the prescribing doctor you take bempedoic acid; an alternative antibiotic is usually available.

Where can I discuss statin alternatives in Singapore?

A cardiologist or lipid specialist can review whether your statin intolerance is genuine and which alternative suits you best. At Paragon Medical Centre on Orchard Road, a first consultation typically costs SGD 150 to SGD 350. Bring your cholesterol results, a full medication list and any history of gout or tendon injury.