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# Ticagrelor (Brilinta)
## Overview
Ticagrelor is a direct-acting, reversible P2Y12 platelet inhibitor.
## Primary Indications
* **Acute Coronary Syndrome (ACS):** To reduce the rate of thrombotic cardiovascular events in patients with ACS, including unstable angina and myocardial infarction (MI) with or without ST-segment elevation, with a history of prior MI.
* **Secondary Prevention in Patients with History of MI:** To reduce the rate of thrombotic cardiovascular events in patients with a history of MI and at least one additional risk factor for occlusive thrombotic events.
## Adult Dosing
* **ACS:**
* **Loading Dose:** 180 mg orally once.
* **Maintenance Dose:** 90 mg orally twice daily for at least 12 months. In patients treated with ticagrelor and aspirin, the maintenance dose may be reduced to 60 mg twice daily after 12 months of treatment.
* **Secondary Prevention in Patients with History of MI:**
* **Maintenance Dose:** 60 mg orally twice daily.
## Pediatric Dosing
* Dosing for pediatric patients is not established.
## Dose Adjustments
* **Renal Impairment:** No dose adjustment is recommended. However, ticagrelor may have increased bleeding risk in patients with severe renal impairment.
* **Hepatic Impairment:** No dose adjustment is recommended. However, use with caution in patients with severe hepatic impairment.
## Contraindications
* Active pathological bleeding.
* History of transient ischemic attack (TIA) or stroke.
* Hypersensitivity to ticagrelor or any component of the formulation.
## Adverse Effects
* **Major Bleeding:** Most common serious adverse effect.
* **Dyspnea:** Can occur and may be transient.
* **Ventricular pauses:** Can occur, especially in patients with pre-existing risk factors.
* **Bradycardia:** Asymptomatic ventricular pauses are common.
* **Other:** Bruising, hypercholesterolemia, increased serum creatinine.
## Key Drug Interactions
* **CYP3A4 Inhibitors/Inducers:** Ticagrelor is a substrate of CYP3A4. Concomitant use with strong CYP3A4 inhibitors may increase ticagrelor exposure and risk of bleeding. Concomitant use with strong CYP3A4 inducers may decrease ticagrelor exposure.
* **Aspirin:** Concurrent use with aspirin is recommended unless contraindicated. Higher doses of aspirin (>100 mg) may reduce the antiplatelet effect of ticagrelor and should be avoided.
* **Other Antiplatelet Agents/Anticoagulants:** Increased risk of bleeding. Use with caution.
## Monitoring
* Monitor for signs and symptoms of bleeding.
* Monitor lipid profiles.
* Monitor renal function.
## Clinical Pearls
* Ticagrelor is a reversible P2Y12 inhibitor, allowing for more rapid return of platelet function compared to clopidogrel, which may be beneficial in patients requiring urgent surgery.
* The recommended maintenance dose for ACS is 90 mg BID for at least 12 months, followed by a potential de-escalation to 60 mg BID.
* For secondary prevention in patients with a history of MI, the maintenance dose is 60 mg BID.
* Patients experiencing dyspnea should be assessed to rule out other causes.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the current prescribing information and relevant clinical guidelines for complete details before making any treatment decisions.
