Urate dynamics, gout events, and tolerability of bempedoic acid for primary ASCVD prevention: a real-world retrospective review from rural primary care in England

Background Bempedoic acid has emerged as a viable non-statin lipid-lowering therapy for patients requiring primary prevention of atherosclerotic cardiovascular disease (ASCVD), particularly where statin intolerance limits optimisation of LDL-C reduction. As bempedoic acid may increase serum urate levels, concerns remain about the potential development of hyperuricaemia or gout, especially in older, multimorbid populations typical of UK primary care. However, real-world evidence describing urate trends and gout incidence in these settings remains limited. Methods A retrospective review was conducted of 708 adults prescribed bempedoic acid or bempedoic acid/ezetimibe within a rural primary care practice in England between 2021 and 2025. Demographic data, longitudinal serum urate measurements, new diagnoses of gout or hyperuricaemia, and reasons for treatment discontinuation were extracted and analysed. The British Society for Rheumatology (BSR) urate target of <0.30 mmol/L served as the reference threshold. Results The cohort comprised 336 men and 372 women, with a mean age of 69.2 years (SD 10.2). At baseline, 68 individuals (9.6%) had a documented history of gout or hyperuricaemia. Mean urate levels were 0.352 mmol/L at baseline, 0.367 mmol/L at 110 days, and 0.293 mmol/L at 402 days post-initiation. Following treatment initiation, 17 patients (2.4%) were newly identified with hyperuricaemia or gout, a finding likely influenced by increased biochemical surveillance rather than a clinically meaningful rise in incidence. Only one patient discontinued therapy due to urate elevation, with normalisation occurring within six weeks. Five patients experienced gout flares or new hyperuricaemia temporally associated with treatment. Overall, urate-related treatment cessation was rare, and most patients continued therapy or were transitioned to ezetimibe monotherapy. Discussion: Observed changes in urate were modest and generally clinically manageable. Gout events were infrequent and aligned with expected patterns in an older, multimorbid cohort in whom age, sex, metabolic comorbidities, and renal impairment remain predominant contributors to gout risk. The low discontinuation rate suggests that bempedoic acid is well tolerated in routine primary care when standard monitoring and patient counselling are provided. These findings indicate that concerns regarding clinically significant gout induction may be overstated in real-world practice. Conclusion In this rural primary care cohort, bempedoic acid was well tolerated with respect to urate elevation and gout occurrence when used for primary ASCVD prevention. Hyperuricaemia-related discontinuation was uncommon. With structured follow-up, clear patient counselling, and appropriate management strategies, bempedoic acid remains a robust therapeutic option for LDL-C reduction in statin-intolerant patients.