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# Ticagrelor
## Overview
Ticagrelor is an oral, direct-acting, reversible P2Y12 receptor antagonist that inhibits platelet activation and aggregation.
## Primary Indications
Ticagrelor is indicated to reduce the rate 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, or as clinically indicated. In patients with ACS who are at high risk for an ischemic event and not at high risk for bleeding, a dose of 60 mg twice daily may be considered for extended treatment beyond 12 months.
* **History of MI (at least 1 year post-MI):**
* For patients with a history of MI at least 1 year prior, who are also at high risk for an occlusive thrombotic event, ticagrelor 60 mg orally twice daily can be used in combination with aspirin.
## Pediatric Dosing
Ticagrelor is not recommended for use in pediatric patients.
## Dose Adjustments
* **Renal Impairment:** No dose adjustment is necessary for mild to moderate renal impairment. Caution is advised in severe renal impairment due to limited data.
* **Hepatic Impairment:** No dose adjustment is necessary for mild to moderate hepatic impairment. Ticagrelor is contraindicated in severe hepatic impairment.
## Contraindications
* Active pathological bleeding.
* History of intracerebral hemorrhage.
* Hypersensitivity to ticagrelor or any of its components.
* Severe hepatic impairment.
## Adverse Effects
* **Common:** Dyspnea, bleeding (including fatal and life-threatening), bradycardia, hyperkalemia, accidental trauma, contusions.
* **Serious:** Significant bleeding, ventricular pauses.
## Key Drug Interactions
* **CYP3A4 Substrates/Inhibitors/Inducers:** Ticagrelor is a moderate inhibitor of CYP3A4. Concomitant use with strong CYP3A4 inhibitors (e.g., ketoconazole, ritonavir) may increase ticagrelor exposure; avoid or use with caution. Concomitant use with strong CYP3A4 inducers (e.g., rifampin, carbamazepine) may decrease ticagrelor exposure; use with caution.
* **Other Antiplatelets/Anticoagulants:** Increased risk of bleeding. Use with caution and consider the combined risk.
## Monitoring
* Monitor for signs and symptoms of bleeding.
* Monitor for bradycardia, especially in patients with risk factors.
* Monitor potassium levels, particularly in patients with renal impairment or hyperkalemia.
## Clinical Pearls
* Ticagrelor should be initiated as soon as possible after the onset of ACS or at the time of percutaneous coronary intervention (PCI).
* Discontinuation of ticagrelor should be avoided as it can increase the risk of thrombotic events. If discontinuation is necessary, ensure appropriate management of bleeding risk and potential for recurrent ischemia.
* Ticagrelor can be taken with or without food.
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*This information is intended as a summary and does not replace comprehensive drug information resources. Always consult the most current prescribing information and clinical guidelines before making treatment decisions.*
