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# Ticagrelor
## Overview
Ticagrelor is a direct-acting, reversibly binding P2Y12 receptor antagonist used to prevent thrombotic events.
## Primary Indications
* Reduction of thrombotic cardiovascular events in patients with acute coronary syndrome (ACS) or a history of myocardial infarction (MI) who are at risk for further events.
* Prevention of thrombotic events in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI).
## Adult Dosing
* **ACS:** 180 mg orally as a single loading dose, followed by 90 mg orally twice daily.
* **STEMI (PCI):** 180 mg orally as a single loading dose, followed by 90 mg orally twice daily.
* **Secondary prevention (post-MI):** After at least 12 months of dual antiplatelet therapy (DAPT) in ACS patients, ticagrelor 95 mg orally twice daily may be considered. In patients with a history of MI, ticagrelor 60 mg orally twice daily may be considered.
## Pediatric Dosing
No established pediatric dosing.
## Dose Adjustments
No dose adjustment is necessary for patients with mild to moderate renal or hepatic impairment. Use with caution in severe renal or hepatic impairment due to limited data.
## Contraindications
* Active pathological bleeding.
* History of transient ischemic attack (TIA) or stroke.
* Concomitant use with strong CYP3A4 inhibitors.
* Known hypersensitivity to ticagrelor.
## Adverse Effects
* **Common:** Dyspnea, bleeding (major and minor), bradyarrhythmia, dizziness, rash.
* **Serious:** Severe bleeding, intracranial hemorrhage, ventricular pauses.
## Key Drug Interactions
* **CYP3A4 Substrates:** Ticagrelor is a moderate inhibitor of CYP3A4. Avoid concomitant use with strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, clarithromycin) and strong CYP3A4 inducers (e.g., rifampin, carbamazepine).
* **Other Anticoagulants/Antiplatelets:** Increased risk of bleeding. Monitor closely.
* **Aspirin:** Generally co-administered. Dose of aspirin may need adjustment based on indication and local protocol.
* **Statins:** Ticagrelor can increase statin levels, particularly simvastatin and atorvastatin.
## Monitoring
* **Bleeding:** Assess for signs and symptoms of bleeding.
* **Bradycardia:** Monitor heart rate, especially in patients with risk factors.
* **Renal and Hepatic Function:** Monitor periodically, especially in patients with severe impairment.
## Clinical Pearls
* The loading dose is crucial for rapid platelet inhibition.
* Ticagrelor has a faster onset and offset of action compared to clopidogrel.
* Dyspnea is a common side effect and may require discontinuation if severe or persistent.
* Ticagrelor is not a P-glycoprotein inhibitor.
**Disclaimer:** This information is intended for clinical decision-making and does not replace professional judgment or full prescribing information. Always verify current prescribing information and consult relevant guidelines.
