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# Ticagrelor
## Overview
Ticagrelor is a 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).
* In combination with aspirin, for prevention of further atherosclerotic events in patients with a history of MI.
## Adult Dosing
* **ACS:**
* **Loading Dose:** 180 mg orally once.
* **Maintenance Dose:** 90 mg orally twice daily for up to 12 months, or as clinically indicated.
* **Post-MI ( $\geq$ 1 year after MI and at least 2 years since last PCI/stent):**
* **Maintenance Dose:** 60 mg orally twice daily.
## Pediatric Dosing
* The safety and efficacy of ticagrelor in pediatric patients have not been established.
## Dose Adjustments
* No dose adjustment is required for patients with mild to moderate renal impairment.
* No dose adjustment is required for patients with mild to moderate hepatic impairment.
* Use with caution in severe renal or hepatic impairment; data is limited.
## Contraindications
* Active pathological bleeding (e.g., intracranial hemorrhage, gastrointestinal bleeding).
* History of transient ischemic attack (TIA) or stroke.
* Known hypersensitivity to ticagrelor or any of its components.
## Adverse Effects
* **Most Common:** Bleeding (major and minor), dyspnea.
* **Other:** Bradycardia, ventricular pauses, increased serum creatinine, hyperuricemia, accidental trauma.
## Key Drug Interactions
* **CYP3A4 Substrates (e.g., simvastatin, atorvastatin):** Ticagrelor inhibits CYP3A4, which can increase concentrations of these drugs. Avoid concurrent use or use lower doses of the CYP3A4 substrate if possible.
* **Strong CYP3A4 Inducers (e.g., rifampin, carbamazepine, phenytoin):** May decrease ticagrelor efficacy.
* **P-glycoprotein (P-gp) Inhibitors (e.g., cyclosporine):** May increase ticagrelor concentrations.
* **Aspirin:** Increased risk of bleeding when used in combination.
* **Other Antiplatelets and Anticoagulants:** Increased risk of bleeding.
## Monitoring
* Monitor for signs and symptoms of bleeding.
* Assess for dyspnea.
* Renal and hepatic function may be monitored periodically, especially in patients with severe impairment.
## Clinical Pearls
* Ticagrelor should be taken for the duration recommended by the prescribing physician, even after hospital discharge.
* If a dose is missed, the patient should take the next dose at the regularly scheduled time and not double the dose.
* Discontinuation of ticagrelor should be avoided if possible, as it can increase the risk of thrombotic events. If discontinuation is necessary, restart as soon as possible.
* Ticagrelor is a reversible P2Y12 inhibitor and has a faster onset and offset of action compared to clopidogrel.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and institutional guidelines before making clinical decisions.*
