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# Ticagrelor ## Overview Ticagrelor is an oral, direct-acting, reversible P2Y12 receptor antagonist. ## Primary Indications * Reduction of thrombotic cardiovascular events in patients with acute coronary syndrome (ACS) or a history of myocardial infarction (MI). * Used in combination with aspirin. ## Adult Dosing * **ACS:** Loading dose: 180 mg orally once. Maintenance dose: 90 mg orally twice daily for up to 12 months. * **History of MI (1 year or older post-MI):** 60 mg orally twice daily. ## Pediatric Dosing Ticagrelor is not recommended in pediatric patients due to a lack of data. ## Dose Adjustments * **Renal Impairment:** No dose adjustment necessary for mild to moderate renal impairment. Use with caution in severe renal impairment. * **Hepatic Impairment:** No dose adjustment necessary for mild to moderate hepatic impairment. Avoid use in severe hepatic impairment. ## Contraindications * Active pathological bleeding. * History of transient ischemic attack (TIA) or stroke. * Known hypersensitivity to ticagrelor or any of its components. * Concomitant use with strong CYP3A4 inhibitors is generally contraindicated. ## Adverse Effects * **Common:** Dyspnea, bleeding (major and minor, including gastrointestinal and intracranial), contusion. * **Serious:** Serious bleeding events, ventricular pauses (especially in patients with a history of bradycardia), hyperkalemia. ## Key Drug Interactions * **CYP3A4 Substrates:** Ticagrelor is a moderate inhibitor of CYP3A4. Avoid concomitant use with strong CYP3A4 inhibitors (e.g., ketoconazole, clarithromycin) and strong CYP3A4 inducers (e.g., rifampin, carbamazepine). * **Aspirin:** Should be used concurrently in ACS patients. Higher doses of aspirin may decrease the efficacy of ticagrelor and increase bleeding risk. * **Other Antiplatelets/Anticoagulants:** Increased risk of bleeding. Use with caution. * **RhH Inhibitors (e.g., P-glycoprotein inhibitors):** Ticagrelor is a substrate for P-gp. Co-administration with strong P-gp inhibitors may increase ticagrelor exposure. ## Monitoring * Monitor for signs and symptoms of bleeding. * Monitor for dyspnea, especially in patients with a history of bronchospastic disease. * Monitor potassium levels, particularly in patients with risk factors for hyperkalemia. ## Clinical Pearls * Ticagrelor is a reversible P2Y12 inhibitor, allowing for faster offset of platelet inhibition compared to clopidogrel. * The maintenance dose for patients with a history of MI (other than ACS) is 60 mg twice daily, which is lower than the ACS dose. * Dyspnea is a common side effect and typically resolves with continued therapy; however, it should be evaluated for other causes. * Discontinuation of ticagrelor increases the risk of thrombotic events. Consider the risks and benefits before stopping therapy prematurely. *** *This information is for educational purposes only and does not substitute for professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment. Prescribing information can change; verify current prescribing information for Ticagrelor before use.*