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# Ticagrelor
## Overview
Ticagrelor is a direct-acting, reversible P2Y12 platelet inhibitor.
## Primary Indications
* **Acute Coronary Syndromes (ACS):** In combination with aspirin, for the reduction of thrombotic cardiovascular events in patients with a history of myocardial infarction (MI).
* **Patients with a history of MI:** For the prevention of further atherothrombotic events.
## Adult Dosing
* **Loading Dose:** 180 mg orally once.
* **Maintenance Dose:** 90 mg orally twice daily for at least 12 months, or until a decision is made to discontinue antiplatelet therapy.
* In patients who are not at high risk for bleeding and are tolerating ticagrelor, the maintenance dose may be reduced to 60 mg twice daily after the first year.
* **Maximum Dose:** Not applicable; standard doses are 180 mg loading and 90 mg maintenance.
## Pediatric Dosing
* No established pediatric dosing. Safety and efficacy have not been studied in this population.
## Dose Adjustments
* **Renal Impairment:** No dose adjustment needed for mild to severe renal impairment.
* **Hepatic Impairment:** No dose adjustment needed for mild to moderate hepatic impairment. Caution is advised in severe hepatic impairment due to lack of data.
## Contraindications
* Active pathological bleeding.
* History of intracranial hemorrhage.
* Known hypersensitivity to ticagrelor or any of its excipients.
## Adverse Effects
* **Common:** Dyspnea, bleeding (including fatal and serious bleeding), bradycardia, increased serum creatinine, hyperuricemia.
* **Serious:** Life-threatening bleeding, significant bleeding events.
## Key Drug Interactions
* **CYP3A4 Inhibitors/Inducers:** Ticagrelor is a substrate of CYP3A4. Strong inhibitors (e.g., ketoconazole, ritonavir) can increase ticagrelor exposure; strong inducers (e.g., rifampin, carbamazepine) can decrease exposure.
* **Aspirin:** Concomitant use increases bleeding risk. Doses of aspirin >100 mg may reduce the efficacy of ticagrelor; therefore, the use of aspirin should be limited to a low daily dose.
* **Other Antiplatelets/Anticoagulants:** Increased risk of bleeding.
* **Statins:** Coadministration with simvastatin or atorvastatin may increase statin exposure.
## Monitoring
* Monitor for signs and symptoms of bleeding.
* Assess for dyspnea.
* Periodic assessment of renal function and uric acid levels may be considered, especially in patients with risk factors.
## Clinical Pearls
* Ticagrelor is a reversible P2Y12 inhibitor, unlike clopidogrel, and has a faster onset and offset of action.
* Dyspnea is a common side effect and is generally not a contraindication to continue therapy unless severe or bothersome.
* A low daily dose of aspirin (e.g., 75-100 mg) is recommended for most patients taking ticagrelor. Higher doses of aspirin may diminish ticagrelor's antiplatelet effect.
* Discontinuation of ticagrelor increases the risk of thrombotic events. If ticagrelor must be discontinued, consider the risks and benefits of resuming therapy or initiating alternative antiplatelet therapy.
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*Please verify current prescribing information and consult with a healthcare professional for specific patient management decisions.*
