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# Ticagrelor
## Overview
Ticagrelor is a direct-acting, reversibly binding P2Y12 receptor antagonist used to reduce the rate of thrombotic cardiovascular events in patients with acute coronary syndrome (ACS) or a history of myocardial infarction (MI).
## Primary Indications
* Reduction of thrombotic cardiovascular events in patients with Acute Coronary Syndrome (ACS).
* Reduction of thrombotic cardiovascular events in patients with a history of MI.
## Adult Dosing
* **ACS:**
* Loading Dose: 180 mg orally once.
* Maintenance Dose: 90 mg orally twice daily for at least 12 months.
* Dose reduction to 60 mg orally twice daily may be considered after 12 months in patients who have had an ACS event, particularly those at high risk for bleeding.
* **History of MI:**
* Maintenance Dose: 60 mg orally twice daily.
## Pediatric Dosing
* There is no established pediatric dosing for ticagrelor.
## Dose Adjustments
* **Hepatic Impairment:** No dose adjustment required in mild to moderate hepatic impairment. Use with caution in severe hepatic impairment.
* **Renal Impairment:** No dose adjustment required in mild to moderate renal impairment. Use with caution in severe renal impairment.
## Contraindications
* Active pathological bleeding.
* History of transient ischemic attack (TIA) or stroke.
* Known hypersensitivity to ticagrelor or any of its excipients.
## Adverse Effects
* **Most Common:** Dyspnea, bradycardia, bleeding (including major bleeding).
* **Serious:** Significant bleeding, ventricular pauses, hyperkalemia.
## Key Drug Interactions
* **CYP3A4 Inhibitors/Inducers:** Ticagrelor is a substrate of CYP3A4. Avoid strong CYP3A4 inhibitors (e.g., ketoconazole, clarithromycin) and inducers (e.g., rifampin, carbamazepine).
* **Strong CYP3A4 inhibitors:** Concomitant use with strong CYP3A4 inhibitors may increase ticagrelor plasma concentrations.
* **Statins:** Ticagrelor can increase simvastatin and atorvastatin exposure; consider lower doses of these statins.
* **Other Antithrombotics:** Increased risk of bleeding with coadministration of aspirin (beyond the initial loading dose in ACS), other P2Y12 inhibitors, heparin, warfarin, and GPIIb/IIIa inhibitors.
## Monitoring
* Monitor for signs and symptoms of bleeding.
* Monitor for bradycardia.
* Consider serum potassium levels, especially in patients with risk factors for hyperkalemia.
## Clinical Pearls
* Ticagrelor's 90 mg dose is typically used for 12 months in ACS patients. The 60 mg dose is for maintenance in patients with a history of MI or for select ACS patients after 12 months.
* Ticagrelor should not be stopped prematurely due to the increased risk of thrombotic events. If a temporary interruption of treatment is necessary for surgical procedures, reinitiate as soon as possible.
* Dyspnea is a common side effect and may not be clinically significant; however, it warrants evaluation.
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*Disclaimer: This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and relevant clinical guidelines before making treatment decisions.*
