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# Ticagrelor
## Overview
Ticagrelor is an orally administered, direct-acting, reversible P2Y12 platelet inhibitor.
## Primary Indications
* Inhibition of platelet aggregation in patients with a history of myocardial infarction (MI) or with acute coronary syndrome (ACS).
* Reduction of thrombotic cardiovascular events in patients with ACS or a history of MI.
## Adult Dosing
* **ACS:** An initial loading dose of 180 mg orally once, followed by 90 mg orally twice daily.
* **History of MI (at least 1 year ago) and high risk for occlusive vascular events:** 60 mg orally twice daily.
* **Concomitant use with aspirin:** Ticagrelor is intended for use in combination with aspirin and other antiplatelet agents. The dose and duration of aspirin therapy should be guided by local protocols and clinical assessment.
## Pediatric Dosing
There is no established pediatric dosing for ticagrelor.
## Dose Adjustments
No dose adjustment is required for patients with mild to severe hepatic impairment. Ticagrelor is not recommended in patients with severe hepatic impairment. No dose adjustment is required for patients with renal impairment.
## Contraindications
* Active pathological bleeding.
* History of intracranial hemorrhage.
* Hypersensitivity to ticagrelor or any of its excipients.
## Adverse Effects
* **Most Common:** Dyspnea, bleeding (including life-threatening and fatal bleeding), bradycardia.
* **Other:** Ventricular pauses, thrombocytopenia, hyperkalemia.
## Key Drug Interactions
* **CYP3A4 Inhibitors/Inducers:** Ticagrelor is a substrate of CYP3A4. Concomitant use with strong CYP3A4 inhibitors (e.g., ketoconazole, clarithromycin) can increase ticagrelor exposure. Concomitant use with strong CYP3A4 inducers (e.g., rifampin, carbamazepine) can decrease ticagrelor exposure.
* **Anticoagulants (e.g., warfarin, heparin):** Increased risk of bleeding.
* **NSAIDs:** Increased risk of bleeding.
* **Aspirin:** While generally used concomitantly, higher doses of aspirin may increase bleeding risk.
## Monitoring
* Monitor for signs and symptoms of bleeding.
* Monitor for dyspnea.
* Periodically monitor serum potassium levels, especially in patients with risk factors for hyperkalemia.
## Clinical Pearls
* Ticagrelor is a reversible P2Y12 inhibitor, which may be advantageous in patients requiring urgent surgery compared to irreversible inhibitors.
* Dyspnea is a common side effect and is usually mild and transient; it often resolves with continued therapy.
* Patients aged 75 years or older with a history of MI and no history of stroke or TIA treated with ticagrelor 90 mg twice daily had an increased risk of fatal bleeding, disabling, or intracranial bleeding compared to placebo.
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*This information is intended for healthcare professionals and does not replace professional medical advice. Always consult the most current prescribing information and your institution's protocols.*
