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# Ticagrelor (Brilinta)
## Overview
Ticagrelor is a direct-acting, reversible P2Y12 platelet inhibitor. It is part of dual antiplatelet therapy (DAPT).
## 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 at least 12 months. In patients who tolerate ticagrelor and have not had a moderate or severe bleeding event, treatment may be extended. Decision for extending treatment beyond 12 months should be individualized.
* **Post-MI (at least 1 year after ACS/MI, on aspirin):**
* **Maintenance Dose:** 60 mg orally twice daily.
## Pediatric Dosing
There is no established pediatric dosing for ticagrelor.
## Dose Adjustments
* **Hepatic Impairment:** No dose adjustment necessary. Ticagrelor is cleared by hepatic metabolism.
* **Renal Impairment:** No dose adjustment necessary.
## Contraindications
* Active pathological bleeding.
* History of intracranial hemorrhage.
* Known hypersensitivity to ticagrelor or any of its excipients.
## Adverse Effects
* **Most Common:** Dyspnea, bleeding (including life-threatening), bradycardia.
* **Other:** Ventricular pauses, increased serum creatinine, cough, diarrhea, rash.
## Key Drug Interactions
* **CYP3A4 Substrates:** Ticagrelor is a moderate inhibitor of CYP3A4. Avoid coadministration with strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, clarithromycin) and strong CYP3A4 inducers (e.g., rifampin, carbamazepine, phenytoin).
* **Warfarin:** Increased risk of bleeding. Monitor INR closely.
* **NSAIDs:** Increased risk of bleeding.
* **Aspirin:** Concomitant use is generally recommended in ACS and post-MI patients.
## Monitoring
* **Bleeding:** Monitor for signs and symptoms of bleeding.
* **Bradycardia:** Monitor heart rate, especially in patients with risk factors for bradycardia.
* **Renal Function:** Monitor serum creatinine.
## Clinical Pearls
* Ticagrelor has a faster onset and offset of action compared to clopidogrel.
* Dyspnea is a common side effect, often transient, and usually does not require discontinuation.
* For patients unable to swallow whole tablets, ticagrelor tablets can be crushed and mixed with water, orange juice, or applesauce and consumed immediately. The mixture can also be prepared with milk or soy milk but should be consumed immediately. The crushed tablet slurry should be followed by more food to ensure complete ingestion.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the current prescribing information and relevant guidelines for complete details and to ensure patient-specific appropriateness.
