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# Ticagrelor (Brilinta)
## Overview
Ticagrelor is an oral, direct-acting P2Y12 platelet inhibitor used to prevent thrombotic events. It is a member of the cyclopentyltriazolopyrimidine (CPTP) class.
## Primary Indications
* In combination with aspirin for the prevention of thrombotic cardiovascular events (including stent thrombosis) in patients with a history of myocardial infarction (MI).
* In combination with aspirin for the prevention of thrombotic cardiovascular events in patients with acute coronary syndrome (ACS).
## Adult Dosing
* **ACS:** Loading dose of 180 mg orally once, followed by 90 mg orally twice daily.
* **Post-MI (history of MI > 1 year ago):** 60 mg orally twice daily.
* Duration of therapy should be guided by patient-specific factors and clinical assessment.
## Pediatric Dosing
Dosing in pediatric patients is not established.
## Dose Adjustments
No dose adjustment is required for patients with mild to moderate hepatic impairment. Use with caution in severe hepatic impairment. No dose adjustment is needed for mild to moderate renal impairment. Data is limited in severe renal impairment.
## Contraindications
* Active pathological bleeding.
* History of transient ischemic attack (TIA) or stroke.
* Known hypersensitivity to ticagrelor or any of its components.
## Adverse Effects
The most common and serious adverse effect is bleeding. Other common adverse effects include dyspnea, bradycardia, and accidental trauma.
## Key Drug Interactions
* **CYP3A4 Substrates:** Ticagrelor is a moderate inhibitor of CYP3A4. Avoid concurrent use with strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, clarithromycin) and potent CYP3A4 substrates (e.g., simvastatin, lovastatin, atorvastatin) where possible, or use caution and consider dose reduction of the substrate.
* **Aspirin:** Additive antiplatelet effects and increased bleeding risk when used in combination.
* **Other Antiplatelets/Anticoagulants:** Increased risk of bleeding.
* **UGT1A1/UGT1A9 Substrates:** Ticagrelor inhibits UGT1A1/UGT1A9. Use caution with medications metabolized by these enzymes (e.g., irinotecan, morphine, bilirubin).
## Monitoring
* Monitor for signs and symptoms of bleeding.
* Monitor heart rate, especially in patients with pre-existing bradyarrhythmias or those taking other medications that can cause bradycardia.
## Clinical Pearls
* Ticagrelor is a reversible P2Y12 inhibitor, unlike clopidogrel.
* Dyspnea is a common side effect and can occur without underlying pulmonary disease. It is usually mild and transient.
* Maintenance dose of 60 mg twice daily is used for patients who have completed 1 year of therapy for ACS or for those with a history of MI greater than 1 year ago.
* Discontinuation of ticagrelor should be avoided unless absolutely necessary due to increased risk of thrombotic events.
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**Disclaimer:** 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 ensure patient-specific care.
