Alirocumab therapy causing plantar bullae in a patient with hypercholesterolemia

A 70-year-old Caucasian male with a past medical history of hypertension, hyperlipidemia, atherosclerotic cardiovascular disease (ASCVD) manifesting as two myocardial infarctions requiring three stent placements, gastroesophageal reflux disease (GERD) and obstructive sleep apnea (OSA) was seen in the endocrine clinic for management of his hyperlipidemia. He had a positive family history for hyperlipidemia in both his mother and sister. The latter having premature ASCVD since she had a myocardial infarction in her forties. He denied smoking cigarettes, ingesting alcohol and any substance abuse. In 1993, the patient was found to have elevated lipids and was placed on different cholesterol lowering agents over the years including fluvastatin, lovastatin, pravastatin, atorvastatin, niacin, fenofibrate, ezetimibe and colestipol. He could not tolerate statin therapy because of myalgias and experienced gastro-intestinal side effects with both niacin and colestipol. Following his initial evaluation at the endocrine clinic and his high risk for ASCVD, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor therapy was considered based on the most recent AHA/ACC Multi-society Cholesterol Guidelines. He did not have tendon xanthoma or diminished pulses. His-lipid profile at this visit revealed a total Cholesterol 330 mg/dl (all reference ranges provided in parentheses, <200 mg/dl); Triglyceride 121 mg/dl (<150 mg/dl); LDL-C-247 mg/dl (<100 mg/dl); HDL-C-59 mg/dl (>40 mg/dl). Other pertinent laboratories revealed a creatinine 1.26 mg/dl (0.5–1.1); albumin 4.5 g/dl (3.3–4.8), TSH-1.53 uIU/mL (0.34–5.60), HBAIC 5.9% (<6.5%).His-urine was negative for protein. Alirocumab was recommended by the VA pharmacy and was initiated at a dose of 75 mg subcutaneous injection every 2 weeks in addition to ezetimibe.