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# Ticagrelor
## Overview
Ticagrelor is a direct-acting, reversible, P2Y12 platelet inhibitor.
## Primary Indications
* Reduction of thrombotic cardiovascular events in patients with acute coronary syndrome (ACS) or a history of myocardial infarction (MI).
## Adult Dosing
* **ACS:**
* **Loading Dose:** 180 mg orally once.
* **Maintenance Dose:** 90 mg orally twice daily for up to 12 months, or as clinically indicated.
* **History of MI (within the last 2 years) and high risk for occlusive thrombotic events:**
* **Maintenance Dose:** 60 mg orally twice daily.
## Pediatric Dosing
* Safety and efficacy in pediatric patients have not been established.
## Dose Adjustments
* No dose adjustments are required for renal or hepatic impairment. However, caution is advised in severe hepatic impairment.
## Contraindications
* Known hypersensitivity to ticagrelor or any of its excipients.
* Active pathological bleeding.
## Adverse Effects
* **Most Common:** Dyspnea, bradycardia, diarrhea, rash, ventricular pauses.
* **Serious:** Bleeding (including fatal and life-threatening), severe bradycardia.
## Key Drug Interactions
* **CYP3A4 Substrates:** Ticagrelor is a moderate inhibitor of CYP3A4. Avoid co-administration with strong CYP3A4 inhibitors (e.g., ketoconazole, clarithromycin). Co-administration with moderate CYP3A4 inhibitors may require caution.
* **CYP3A4 Inducers:** Co-administration with strong CYP3A4 inducers (e.g., rifampin, phenytoin, carbamazepine) may decrease ticagrelor exposure and efficacy.
* **Aspirin:** When used for ACS, co-administration with aspirin is recommended. For other indications, the benefit of co-administration with aspirin should be weighed against the increased bleeding risk.
## Monitoring
* Monitor for signs and symptoms of bleeding.
* Consider monitoring ECG for bradyarrhythmias, especially in patients with pre-existing risk factors.
## Clinical Pearls
* Ticagrelor has a faster onset and offset of action compared to clopidogrel and is not a prodrug.
* Dose of aspirin when co-administered should be individualized and not exceed 100 mg for secondary prevention.
* Dose of 90 mg twice daily is indicated for ACS patients. The 60 mg twice daily dose is for patients with a history of MI and high risk for thrombotic events, initiated after at least 12 months of therapy with 90 mg twice daily, unless the risk of thrombotic events is high.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines for complete details, as product labeling and recommendations can change.
