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# Ticagrelor
## Overview
Ticagrelor is a direct-acting, reversible P2Y12 receptor antagonist that inhibits adenosine diphosphate (ADP)-induced platelet aggregation.
## Primary Indications
* In combination with aspirin, for the reduction of thrombotic cardiovascular events (including myocardial infarction and stroke) in patients with acute coronary syndrome (ACS) or a history of myocardial infarction (MI).
* In combination with aspirin and clopidogrel, for the reduction of thrombotic cardiovascular events in patients with ACS who have undergone percutaneous coronary intervention (PCI).
## Adult Dosing
* **ACS:** Loading dose of 180 mg orally once, followed by 90 mg orally twice daily for up to 12 months.
* **Secondary prevention in patients with history of MI:** 60 mg orally twice daily. The optimal duration of treatment should be individualized.
## Pediatric Dosing
* Ticagrelor is not approved for use in pediatric patients. Data is insufficient to establish dosing.
## Dose Adjustments
* No dose adjustments are typically required for hepatic or renal impairment, though caution is advised in severe hepatic impairment.
## Contraindications
* Active pathological bleeding (e.g., intracranial hemorrhage, gastrointestinal bleeding).
* History of intracranial hemorrhage.
* Known hypersensitivity to ticagrelor or any component of the formulation.
## Adverse Effects
* **Common:** Dyspnea, bleeding (including life-threatening and fatal bleeding), contusion, bradycardia, atrial fibrillation.
* **Serious:** Major bleeding, ventricular pauses, severe hypersensitivity reactions.
## Key Drug Interactions
* **CYP3A4 Inhibitors/Inducers:** Ticagrelor is a substrate of CYP3A4. Coadministration with strong CYP3A4 inhibitors (e.g., ketoconazole, ritonavir) can increase ticagrelor exposure. Coadministration with strong CYP3A4 inducers (e.g., rifampin, carbamazepine) can decrease ticagrelor exposure.
* **Other Antiplatelet Agents/Anticoagulants:** Increased risk of bleeding. Concomitant use should be carefully considered and monitored.
* **Aspirin:** Generally coadministered; however, higher doses of aspirin (e.g., >100 mg daily) may reduce the effectiveness of ticagrelor.
## Monitoring
* Monitor for signs and symptoms of bleeding.
* Monitor for bradycardia; consider ECG if symptomatic.
* Platelet function tests are not routinely recommended for dose management.
## Clinical Pearls
* Administer the initial 180 mg loading dose as soon as ACS is diagnosed.
* Discontinue ticagrelor 5 days before elective surgery if possible, weighing the risk of bleeding against the risk of thrombotic events.
* Ticagrelor should be taken for the duration prescribed by the healthcare provider, even after hospital discharge.
* Patients with a history of stroke or transient ischemic attack (TIA) who have ACS may benefit from ticagrelor plus aspirin therapy.
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*Disclaimer: 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.*
