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# Ticagrelor (Brilinta)
## Overview
Ticagrelor is a direct-acting, reversibly binding P2Y12 receptor antagonist. It inhibits platelet activation and aggregation.
## Primary Indications
* Reduction of thrombotic cardiovascular events (e.g., myocardial infarction, stroke) in patients with acute coronary syndrome (ACS) or a history of myocardial infarction.
## Adult Dosing
* **ACS:**
* Loading Dose: 180 mg orally once.
* Maintenance Dose: 90 mg orally twice daily for at least 12 months. After 12 months, consider extending therapy.
* **Patients with history of MI (≥ 1 year post-ACS or other MI):**
* 60 mg orally twice daily.
## Pediatric Dosing
* Dosing has not been established in pediatric patients.
## Dose Adjustments
* **Hepatic Impairment:** No dose adjustment necessary, but use with caution in severe hepatic impairment.
* **Renal Impairment:** No dose adjustment necessary.
## Contraindications
* History of intracranial hemorrhage.
* Active bleeding (e.g., gastrointestinal bleeding, internal bleeding).
* Hypersensitivity to ticagrelor or any of its excipients.
## Adverse Effects
* **Common:** Dyspnea, bleeding (including major and minor), contusions.
* **Serious:** Serious bleeding, bradyarrhythmias.
## Key Drug Interactions
* **CYP3A4 Inhibitors/Inducers:** Ticagrelor is a substrate of CYP3A4. Strong inhibitors can increase ticagrelor levels, and strong inducers can decrease them. Avoid co-administration with strong CYP3A4 inhibitors (e.g., ketoconazole, clarithromycin) where possible.
* **CYP3A4 Substrates:** Ticagrelor can increase plasma concentrations of CYP3A4 substrates. Use with caution (e.g., statins).
* **Aspirin:** Usually co-administered with aspirin, but higher aspirin doses may reduce ticagrelor's efficacy.
* **Other Antiplatelet/Anticoagulant Agents:** Increased risk of bleeding. Use with caution and consider the net bleeding risk.
* **Omeprazole:** Reduced ticagrelor exposure. Separate administration if possible.
## Monitoring
* Monitor for signs and symptoms of bleeding.
* Monitor for dyspnea.
## Clinical Pearls
* Ticagrelor is a P2Y12 inhibitor that is taken twice daily, unlike clopidogrel and prasugrel.
* Dyspnea is a common side effect and does not necessarily indicate cardiac issues, but warrants evaluation.
* Discontinuation of ticagrelor prematurely increases the risk of thrombotic events. If urgent surgery is needed, consider the timing of cessation relative to the procedure.
* Ticagrelor is generally preferred over clopidogrel in ACS patients due to superior efficacy, unless there are specific contraindications or bleeding concerns.
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*This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and relevant clinical guidelines before making any treatment decisions.*
