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# Ticagrelor (Brilinta)
## Overview
Ticagrelor is a direct-acting, reversibly binding P2Y12 platelet inhibitor.
## Primary Indications
* **Acute Coronary Syndromes (ACS):** In combination with aspirin, for the prevention of thrombotic events in patients with ACS (unstable angina, non-ST-elevation myocardial infarction, or ST-elevation myocardial infarction) managed with percutaneous coronary intervention (PCI).
* **Myocardial Infarction (MI):** In patients with a history of MI, to reduce the rate of cardiovascular death, MI, and stroke through combination with aspirin.
## Adult Dosing
* **ACS:**
* **Loading Dose:** 180 mg orally once.
* **Maintenance Dose:** 90 mg orally twice daily for at least 12 months. For patients treated with ticagrelor 90 mg twice daily in the ACS setting who are switched to ticagrelor for secondary prevention after MI, a lower dose of 60 mg twice daily may be considered.
* **Secondary Prevention after MI:**
* **Maintenance Dose:** 60 mg orally twice daily. This should be continued for at least 12 months in patients who have had an MI.
## Pediatric Dosing
Dosing for pediatric patients is not established.
## Dose Adjustments
No dose adjustments are required based on age, sex, or race. Dose adjustments are based on indication and patient history.
## Contraindications
* Active pathological bleeding (e.g., peptic ulcer, intracranial hemorrhage).
* History of intracranial hemorrhage.
* Hypersensitivity to ticagrelor or any component of the formulation.
## Adverse Effects
* **Major Bleeding:** Most common serious adverse effect.
* **Dyspnea:** Often transient.
* **Bradycardia:** Can occur due to P2Y12 inhibition.
* **Ventricular pauses:** May be asymptomatic or symptomatic.
* **Hyperuricemia:**
* **Incontinence:**
* **Other:** Bruising, epistaxis, gastrointestinal hemorrhage, contusion.
## Key Drug Interactions
* **CYP3A4 Inhibitors/Inducers:** Ticagrelor is a substrate of CYP3A4. Strong inhibitors (e.g., ketoconazole, clarithromycin) can increase ticagrelor concentrations and risk of bleeding. Strong inducers (e.g., rifampin, phenytoin) can decrease ticagrelor concentrations.
* **Statins:** Ticagrelor can increase simvastatin and lovastatin concentrations; avoid concomitant use of simvastatin >40 mg and lovastatin >20 mg.
* **Other Antiplatelets/Anticoagulants:** Concomitant use increases the risk of bleeding.
* **Aspirin:** Generally used in combination, but increases bleeding risk.
## Monitoring
* **Bleeding:** Monitor for signs and symptoms of bleeding, especially if concomitant anticoagulation is used or risk factors for bleeding are present.
* **Renal Function:** Monitor periodically.
* **Uric Acid:** Monitor periodically, especially in patients with a history of gout.
* **ECG:** Monitor for bradycardia.
## Clinical Pearls
* Ticagrelor is administered orally, twice daily, regardless of food intake.
* For patients switching from another P2Y12 inhibitor, stop the previous agent and start ticagrelor.
* For patients switching to ticagrelor, a loading dose is recommended in the ACS setting.
* The 60 mg twice daily dose is specifically for long-term maintenance after MI.
* Discontinuation of ticagrelor should be avoided if possible, as it increases the risk of thrombotic events, particularly in the setting of ACS.
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*This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines for complete details and to verify dosing and safety information before patient administration.*
