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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 in patients with acute coronary syndrome (ACS).
## Primary Indications
* Reduction of thrombotic cardiovascular events in patients with acute coronary syndrome (ACS) or a history of myocardial infarction (MI).
## Adult Dosing
* **Acute Coronary Syndrome (ACS):** 180 mg orally once every 12 hours for the first week, followed by 90 mg orally once every 12 hours.
* **History of Myocardial Infarction (MI):** For patients with a history of MI who are at least 1 year post-MI and at high risk for an occlusive thrombotic event, consider 60 mg orally once every 12 hours.
## Pediatric Dosing
* Ticagrelor is **not recommended** for use in pediatric patients due to lack of data.
## Dose Adjustments
* No dose adjustment is necessary for patients with hepatic impairment.
* No specific dose adjustments are routinely recommended for renal impairment, however, caution may be advised in severe renal impairment.
## Contraindications
* Active pathological bleeding.
* History of intracranial hemorrhage.
* Known hypersensitivity to ticagrelor or any of its components.
## Adverse Effects
* **Most Common:** Dyspnea, bleeding (major, minor, fatal), bradycardia, ventricular pauses.
* **Serious:** Major bleeding, dyspnea, cerebral hemorrhage, cardiac arrest, ventricular pauses.
## Key Drug Interactions
* **CYP3A4 Inhibitors/Inducers:** Ticagrelor is a substrate of CYP3A4. Concomitant use with strong CYP3A4 inhibitors (e.g., ketoconazole, clarithromycin) can increase ticagrelor exposure. Concomitant use with strong CYP3A4 inducers (e.g., rifampin, carbamazepine) can decrease ticagrelor exposure.
* **P-glycoprotein (P-gp) Inhibitors:** Concomitant use with P-gp inhibitors can increase ticagrelor exposure.
* **Other Antiplatelet Agents/Anticoagulants:** Increased risk of bleeding. Use with caution and monitor for signs of bleeding.
* **Statins:** Concomitant use with simvastatin or lovastatin greater than 40 mg daily is not recommended due to increased risk of myopathy.
## Monitoring
* **Bleeding:** Closely monitor for signs and symptoms of bleeding.
* **Heart Rate:** Monitor for bradycardia and ventricular pauses, especially in patients with pre-existing conditions that may predispose them to bradycardia.
## Clinical Pearls
* Ticagrelor is administered twice daily, regardless of the indication (except for the 60 mg maintenance dose).
* A loading dose is recommended for ACS.
* Patients experiencing significant dyspnea should be evaluated for underlying causes.
* Discontinuation of ticagrelor should be avoided if possible, as premature discontinuation increases the risk of thrombotic events. If discontinuation is necessary, consider the risks and benefits.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and local guidelines for definitive patient care decisions.
