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# Ticagrelor
## Overview
Ticagrelor is an oral P2Y12 platelet inhibitor used to prevent thrombotic events. It is a direct-acting, reversible antagonist.
## Primary Indications
* **Acute Coronary Syndrome (ACS):** To reduce the rate of cardiovascular death, myocardial infarction, and stroke in patients with ACS.
* **Myocardial Infarction (MI) with no ACS:** In patients with a history of MI (at least 1 year prior) to reduce the rate of thrombotic cardiovascular death, MI, and stroke.
## Adult Dosing
* **ACS:** Loading dose of 180 mg orally once, followed by 90 mg orally twice daily.
* **History of MI (at least 1 year prior):** 60 mg orally twice daily.
* **Duration of therapy:** Typically 12 months in ACS patients, or as long as benefit outweighs risk. For patients with a history of MI but no ACS, 60 mg twice daily may be continued long-term.
## Pediatric Dosing
No established pediatric dosing.
## Dose Adjustments
* **Hepatic Impairment:** No dose adjustment necessary. Ticagrelor is not recommended in severe hepatic impairment.
* **Renal Impairment:** No dose adjustment necessary.
## Contraindications
* Active bleeding.
* History of intracerebral hemorrhage.
* Hypersensitivity to ticagrelor or any of its excipients.
## Adverse Effects
* **Most Common:** Dyspnea, bleeding (including life-threatening), bradycardia.
* **Serious:** Bleeding, ventricular pauses, increased serum creatinine, hyperuricemia.
* **Other:** Bruising, dizziness, headache, diarrhea, rash.
## Key Drug Interactions
* **Strong CYP3A4 Inhibitors:** Concomitant use can increase ticagrelor plasma concentrations; caution advised.
* **Strong CYP3A4 Inducers:** Concomitant use can decrease ticagrelor plasma concentrations; may reduce efficacy.
* **Other Antiplatelets/Anticoagulants:** Increased risk of bleeding.
* **Statins:** Ticagrelor can increase statin concentrations, particularly simvastatin and atorvastatin, potentially increasing risk of myopathy. Max simvastatin dose: 40 mg daily. Max atorvastatin dose: 80 mg daily.
* **Digoxin:** Ticagrelor can increase digoxin concentrations; monitor digoxin levels.
## Monitoring
* **Bleeding:** Monitor for signs and symptoms of bleeding.
* **Renal Function:** Monitor serum creatinine and electrolytes, especially in patients with renal impairment.
* **Uric Acid:** Monitor uric acid levels, especially in patients with a history of gout or hyperuricemia.
* **Heart Rate:** Monitor for bradycardia.
## Clinical Pearls
* Ticagrelor has a faster onset and offset of action compared to clopidogrel, and its effect is reversible.
* Dose of aspirin: For ACS, ticagrelor is generally used with aspirin. The optimal dose of aspirin is not well-defined, but doses exceeding 100 mg twice daily are associated with increased bleeding risk. For patients with a history of MI (at least 1 year prior), low-dose aspirin is recommended.
* Discontinuation: Discontinuation of ticagrelor may increase the risk of thrombotic events.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information and local protocols for definitive guidance.*
