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# Ticagrelor
## Overview
Ticagrelor is an oral, direct-acting, reversibly binding P2Y12 receptor antagonist.
## Primary Indications
* Inhibition of platelet aggregation in patients with a history of myocardial infarction (MI) or with acute coronary syndrome (ACS).
* Reduction of thrombotic cardiovascular events.
## Adult Dosing
* **ACS:** Loading dose of 180 mg orally once, followed by 90 mg orally twice daily.
* **History of MI (≥1 year ago) with established atherosclerotic disease:** 60 mg orally twice daily.
* **In combination with aspirin:** For patients with ACS, ticagrelor is indicated in combination with aspirin. For patients with a history of MI, ticagrelor 60 mg can be used with aspirin. The optimal duration of dual antiplatelet therapy (DAPT) varies.
## Pediatric Dosing
* There is no established pediatric dosing for ticagrelor.
## Dose Adjustments
* **Hepatic Impairment:** No dose adjustment is recommended for mild to moderate hepatic impairment. Caution advised in severe hepatic impairment.
* **Renal Impairment:** No dose adjustment is recommended for mild to moderate renal impairment. Caution advised in severe renal impairment.
## Contraindications
* Active pathological bleeding (e.g., intracranial hemorrhage, gastrointestinal bleeding).
* History of transient ischemic attack (TIA) or stroke.
* Hypersensitivity to ticagrelor or any of its excipients.
* Concomitant use with strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, clarithromycin).
## Adverse Effects
* **Common:** Dyspnea, bleeding (including life-threatening), bradycardia, hyperkalemia, rash.
* **Serious:** Major bleeding, significant bradycardic events, angioedema.
## Key Drug Interactions
* **CYP3A4 Inhibitors/Inducers:** Ticagrelor is a substrate of CYP3A4. Concomitant use with strong inhibitors (e.g., ketoconazole, clarithromycin) increases ticagrelor exposure. Concomitant use with strong inducers (e.g., rifampin) decreases ticagrelor exposure.
* **Aspirin:** Concurrent use is common and recommended for ACS patients, but increases bleeding risk.
* **Other Antiplatelets/Anticoagulants:** Increased risk of bleeding.
* **Statins:** Ticagrelor can increase statin exposure, particularly simvastatin and atorvastatin, potentially increasing the risk of myopathy.
## Monitoring
* Monitor for signs and symptoms of bleeding.
* Monitor electrolytes, particularly potassium, especially in patients with risk factors for hyperkalemia.
* Consider baseline and periodic monitoring of liver function tests.
## Clinical Pearls
* Ticagrelor should be initiated as soon as a patient is identified with ACS or has a history of MI and is a candidate for antiplatelet therapy.
* If a dose is missed, patients should take it as soon as they remember and then return to their regular dosing schedule. They should not take two doses at the same time.
* Dispense the lowest possible quantity to minimize potential waste in case of a change in therapy or adverse event.
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*This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines for definitive patient management decisions. This summary does not replace a thorough evaluation of the patient and their specific clinical circumstances.*
