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# Ticagrelor (Brilinta)
## Overview
Ticagrelor is a direct-acting, reversibly binding P2Y12 platelet inhibitor. It is used to reduce the rate of thrombotic cardiovascular events.
## Primary Indications
* In combination with aspirin, for the prevention of thrombotic cardiovascular events in patients with acute coronary syndrome (ACS) or a history of myocardial infarction (MI).
## Adult Dosing
* **ACS:**
* **Loading Dose:** 180 mg orally once.
* **Maintenance Dose:** 90 mg orally twice daily for at least 12 months.
* **Post-MI (following at least 1 year of DAPT):**
* **Maintenance Dose:** 60 mg orally twice daily.
## Pediatric Dosing
* Dosing in pediatric patients is not established.
## Dose Adjustments
* No dose adjustments are recommended for renal or hepatic impairment. However, caution is advised in severe hepatic impairment.
## Contraindications
* Active pathological bleeding.
* History of transient ischemic attack (TIA) or stroke.
* Concomitant use with strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, voriconazole, clarithromycin).
## Adverse Effects
* **Most Common:** Dyspnea, bradycardia, bleeding (including fatal and life-threatening).
* **Other:** Ventricular pauses, increased serum creatinine, increased uric acid.
## Key Drug Interactions
* **CYP3A4 Substrates:** Ticagrelor inhibits CYP3A4, increasing plasma concentrations of substrates (e.g., simvastatin, atorvastatin, certain opioids). Avoid concomitant use or use with caution.
* **CYP3A4 Inhibitors/Inducers:** Avoid strong CYP3A4 inhibitors. Use with caution and monitor for reduced efficacy with strong CYP3A4 inducers.
* **UGT1A1/UGT1A9 Substrates:** Ticagrelor inhibits UGT1A1/UGT1A9, increasing plasma concentrations of substrates (e.g., rifampin, certain chemotherapy agents).
* **Other Antiplatelets/Anticoagulants:** Increased risk of bleeding.
## Monitoring
* Monitor for signs and symptoms of bleeding.
* Monitor for dyspnea.
* Periodic assessment of renal function and serum uric acid.
## Clinical Pearls
* Ticagrelor provides faster and more consistent platelet inhibition compared to clopidogrel.
* Dyspnea is a common side effect and is usually transient; it does not typically indicate underlying cardiopulmonary disease.
* Discontinuation of ticagrelor prematurely increases the risk of stent thrombosis, MI, and death.
* The 60 mg dose is indicated only after at least 1 year of dual antiplatelet therapy (DAPT) in patients with a history of MI.
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**Disclaimer:** This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and your healthcare provider for any medical advice or treatment decisions.
