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# Ticagrelor (Brilinta)
## Overview
Ticagrelor is an orally administered, direct-acting, reversible P2Y12 platelet inhibitor. It is indicated to reduce the rate of thrombotic cardiovascular events in patients with a history of myocardial infarction (MI).
## Primary Indications
* **Acute Coronary Syndrome (ACS):** To reduce the rate of thrombotic cardiovascular events in patients with ACS (unstable angina, non-ST-elevation MI, or STEMI) managed with percutaneous coronary intervention (PCI).
* **History of MI:** To reduce the rate of thrombotic cardiovascular events in patients with a history of MI who are treated with aspirin.
## Adult Dosing
* **ACS:** Loading dose of 180 mg orally once, followed by 90 mg orally twice daily for up to 12 months. Treatment beyond 12 months should be considered on an individual basis.
* **History of MI (≥1 year post-MI):** 60 mg orally twice daily.
## Pediatric Dosing
Ticagrelor is not recommended for use in pediatric patients. Safety and efficacy have not been established.
## Dose Adjustments
* **Hepatic Impairment:** No dose adjustment is recommended for patients with mild to moderate hepatic impairment. Use with caution in severe hepatic impairment.
* **Renal Impairment:** No dose adjustment is necessary for patients with mild to moderate renal impairment. In patients with severe renal impairment, consider the risks and benefits.
* **Age:** No dose adjustment is required based on age.
## Contraindications
* Known hypersensitivity to ticagrelor or any of its excipients.
* Active pathological bleeding.
## Adverse Effects
**Serious:**
* Bleeding (e.g., gastrointestinal, intracranial, genitourinary)
* Dyspnea
* Ventricular pauses/bradycardia
* Cerebral hematoma, subarachnoid hemorrhage, epistaxis
**Common:**
* Bleeding (ecchymosis, contusion, hematuria, gingival bleeding)
* Dyspnea
* Hypertension
* Diarrhea
* Rash
## Key Drug Interactions
* **CYP3A4 Inhibitors/Inducers:** Ticagrelor is a substrate of CYP3A4. Concomitant use with strong CYP3A4 inhibitors may increase ticagrelor exposure. Concomitant use with strong CYP3A4 inducers may decrease ticagrelor exposure.
* **Aspirin:** Increased risk of bleeding. Maintain aspirin therapy as indicated.
* **Other Antiplatelet Agents/Anticoagulants:** Increased risk of bleeding. Use with caution and monitor closely.
* **UGT1A1 Inhibitors/Inducers:** May affect ticagrelor glucuronidation.
* **Digoxin:** Ticagrelor may increase digoxin levels. Monitor digoxin levels and adjust dose as needed.
## Monitoring
* **Bleeding:** Closely monitor for signs and symptoms of bleeding.
* **Renal function:** Monitor periodically.
* **Hepatic function:** Monitor periodically, especially in patients with hepatic impairment.
* **Digoxin levels:** If concomitant use.
## Clinical Pearls
* Ticagrelor is a reversible P2Y12 inhibitor, which may offer advantages in patients requiring urgent surgery.
* The 90 mg dose in ACS is typically continued for 12 months. The 60 mg dose is for patients with a history of MI beyond 1 year.
* Dyspnea is a common side effect and is usually mild and transient. It is not typically a contraindication to therapy.
* Management of bleeding requires discontinuation of ticagrelor and supportive care. The decision to restart therapy should be individualized.
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**Disclaimer:** This information is intended for healthcare professionals and does not substitute for professional medical advice. Always consult the most current prescribing information or your healthcare provider for complete drug information before making any decisions related to patient care.
