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# Ticagrelor (Brilinta)
## Overview
Ticagrelor is an oral, direct-acting, reversible P2Y12 receptor antagonist used to inhibit platelet aggregation. It is a member of the cyclopentyltriazolopyrimidine (CPTP) class.
## Primary Indications
* Reduction of thrombotic cardiovascular events (including myocardial infarction and stroke) in patients with acute coronary syndrome (ACS) or a history of myocardial infarction.
* In combination with aspirin for the prevention of stent thrombosis in patients treated with drug-eluting stents.
## Adult Dosing
* **ACS:** 180 mg orally once as a single loading dose, followed by 90 mg orally twice daily for up to 12 months.
* **Maintenance after ACS/stent thrombosis:** 90 mg orally twice daily.
* **Ischemic events in patients with history of MI:** 60 mg orally twice daily.
## Pediatric Dosing
* There is no established pediatric dosing for ticagrelor.
## Dose Adjustments
* **Renal Impairment:** No dose adjustment necessary.
* **Hepatic Impairment:** No dose adjustment necessary for mild to moderate hepatic impairment. Use with caution in severe hepatic impairment.
## Contraindications
* Active pathological bleeding.
* History of intracranial hemorrhage.
* Hypersensitivity to ticagrelor or any of its components.
## Adverse Effects
* **Most Common:** Dyspnea, bleeding (major and minor), bradycardia.
* **Serious:** Life-threatening bleeding, ventricular pauses, confusional state, transient ischemic attack, stroke, intracranial hemorrhage.
* **Other:** Hypotension, atrial fibrillation, rash, cough.
## Key Drug Interactions
* **CYP3A4 Inhibitors/Inducers:** Ticagrelor is a substrate of CYP3A4. Concomitant use with strong CYP3A4 inhibitors may increase ticagrelor exposure. Concomitant use with strong CYP3A4 inducers may decrease ticagrelor exposure.
* **Aspirin:** Generally used in combination with aspirin. Doses of aspirin greater than 100 mg may reduce the effectiveness of ticagrelor and increase bleeding risk.
* **Other Antiplatelets/Anticoagulants:** Increased risk of bleeding. Use with caution and monitor closely for signs of bleeding.
* **Rho-kinase (ROCK) Inhibitors:** Ticagrelor is a ROCK inhibitor and can increase levels of ROCK inhibitors, potentially leading to hypotension. Avoid concomitant use.
## Monitoring
* Monitor for signs and symptoms of bleeding.
* Monitor for bradycardia.
* Assess for dyspnea.
## Clinical Pearls
* Ticagrelor is a reversible P2Y12 inhibitor, which can be advantageous if urgent surgery is required.
* The loading dose is crucial for rapid onset of platelet inhibition.
* Maintenance dose for ACS is typically 90 mg BID. For patients with a history of MI but not ACS, the maintenance dose is 60 mg BID.
* Dyspnea is a common side effect and may require discontinuation in some patients.
* There is no need to dose adjust for renal or hepatic impairment, but caution is advised in severe hepatic impairment.
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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 safety.*
