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# Ticagrelor ## Overview Ticagrelor is an oral, direct-acting, reversible P2Y12 platelet inhibitor. ## 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. * **Post-MI (at least 1 year after ACS/MI event):** * 90 mg orally twice daily. May be reduced to 60 mg orally twice daily in certain patients (e.g., high bleeding risk, age ≥75 years, low body weight). * **Duration of therapy:** Typically 12 months. Decision to continue beyond 12 months should be individualized based on risk of ischemic events versus bleeding risk. ## Pediatric Dosing * No established pediatric dosing. Use in pediatric populations is not recommended. ## Dose Adjustments * **Renal Impairment:** No dose adjustment needed. * **Hepatic Impairment:** No dose adjustment needed for mild to moderate hepatic impairment. Use with caution in severe hepatic impairment due to lack of data. ## Contraindications * Hypersensitivity to ticagrelor or any component of the formulation. * Active pathological bleeding. * History of intracranial hemorrhage. ## Adverse Effects * **Most Common:** Dyspnea, bleeding (including serious and life-threatening). * **Other:** Ventricular pauses, bradycardia, hyperuricemia, increased serum creatinine. ## Key Drug Interactions * **CYP3A4 Inhibitors:** Increased ticagrelor concentrations. Avoid coadministration with strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, clarithromycin). * **CYP3A4 Inducers:** Decreased ticagrelor concentrations. Avoid coadministration with strong CYP3A4 inducers (e.g., rifampin, phenytoin, carbamazepine). * **Aspirin:** Concurrent use is recommended for ACS, but increases bleeding risk. * **Other Antiplatelets/Anticoagulants:** Increased risk of bleeding. Use with caution. * **Omeprazole/Esomeprazole:** May reduce ticagrelor exposure; consider timing of administration if coadministered. ## Monitoring * Monitor for signs and symptoms of bleeding. * Monitor for dyspnea. * Periodic assessment of bleeding risk vs. ischemic benefit. ## Clinical Pearls * Ticagrelor is a direct-acting P2Y12 inhibitor with a faster onset and offset of action compared to clopidogrel. * It is not a prodrug and does not require metabolic activation. * Dyspnea is a common side effect and is usually not clinically significant, but warrants evaluation to rule out other causes. * Dose of 60 mg twice daily is an option for specific patient populations to reduce bleeding risk, particularly after the initial 12-month period. *** *Disclaimer: This information is intended for educational purposes and does not substitute for professional medical advice. Always consult the current prescribing information and relevant guidelines for definitive treatment decisions.*