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# Ticagrelor (Brilinta)
## Overview
Ticagrelor is an oral P2Y12 platelet inhibitor used to reduce the rate of thrombotic cardiovascular events.
## Primary Indications
* In combination with aspirin, for patients with a history of myocardial infarction (MI) to reduce the rate of cardiovascular death, MI, and stroke.
* In combination with aspirin, for the treatment of acute coronary syndrome (ACS) to reduce the rate of cardiovascular death, MI, stroke, and other events.
## Adult Dosing
* **ACS:** Loading dose of 180 mg orally once, followed by 90 mg orally twice daily for at least 12 months.
* **History of MI:** 90 mg orally twice daily.
* **Maintenance after 12 months of ACS treatment:** Dose may be reduced to 60 mg orally twice daily.
## Pediatric Dosing
* There is no established pediatric dosing for ticagrelor.
## Dose Adjustments
* No dose adjustment is needed for patients with mild to moderate hepatic impairment.
* Use with caution in severe hepatic impairment.
* No dose adjustment is needed for patients with mild to moderate renal impairment.
* Use with caution in severe renal impairment.
## Contraindications
* Active pathological bleeding (e.g., intracranial hemorrhage, gastrointestinal bleeding).
* Known history of transient ischemic attack (TIA) or stroke (in patients with ACS).
* Concomitant use with strong CYP3A4 inhibitors.
## Adverse Effects
* **Common:** Dyspnea, bleeding (including fatal and life-threatening), bradycardia, ventricular pauses, increased serum creatinine, hyperuricemia.
* **Serious:** Major bleeding, non-major clinically relevant bleeding, intracranial hemorrhage, severe allergic reactions.
## Key Drug Interactions
* **CYP3A4 Substrates:** Ticagrelor is a moderate inhibitor of CYP3A4. Avoid concomitant use with strong CYP3A4 inhibitors (e.g., ketoconazole, clarithromycin).
* **CYP3A4 Inducers:** Avoid concomitant use with strong CYP3A4 inducers (e.g., rifampin, carbamazepine).
* **CYP2C19 Substrates:** Ticagrelor can inhibit CYP2C19, potentially increasing the concentration of drugs like clopidogrel, phenytoin, and warfarin.
* **Aspirin:** Concomitant use increases the risk of bleeding.
* **Other Antiplatelets/Anticoagulants:** Concomitant use increases the risk of bleeding.
## Monitoring
* Monitor for signs and symptoms of bleeding.
* Monitor renal function and uric acid levels.
* Electrolyte monitoring may be considered, especially in patients with known electrolyte abnormalities.
## Clinical Pearls
* Ticagrelor is a reversible P2Y12 inhibitor, unlike clopidogrel.
* The 180 mg loading dose is crucial for ACS patients.
* Dyspnea is a common side effect and may require discontinuation if severe.
* Stopping ticagrelor prematurely increases the risk of thrombotic events.
* Dose reduction to 60 mg twice daily may be considered for long-term maintenance after 12 months in ACS patients, based on individual risk assessment.
**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant guidelines before making clinical decisions.
