Ticagrelor

Aka: Ticagrelor, Brilinta

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II. Indications: Prevention of Thrombotic Events

  1. See Platelet ADP Receptor Antagonist
  2. See Antiplatelet Therapy for Vascular Disease
  3. Cerebrovascular Accident Prevention
  4. Coronary Artery Disease Prevention (especially if Aspirin Allergy)
  5. Post-ST Elevation MI (with or without reperfusion)
    1. Ticagrelor is recommended by ACA (2016) over Clopidogrel in Acute Coronary Syndrome and stenting

III. Contraindications

  1. Active Bleeding

IV. Mechanism: Thienopyridine Class

  1. See Platelet ADP Receptor Antagonist

V. Dosing

  1. Requires twice daily dosing (contrast with Clopidogrel which is once daily)
  2. Standard dosing
    1. Brilanta 90 mg orally twice daily
  3. Acute Myocardial Infarction with or without impending PCI
    1. Loading dose: Brilanta 180 mg orally once
    2. Then initiate standard 90 mg twice daily Brilanta dose
    3. Used with Aspirin 81 mg (Dual Antiplatelet Therapy) after PCI
  4. Dosing Adjustments
    1. No dosing adjustment needed in renal and mild hepatic Impairment
    2. Use caution in moderate liver disease and avoid in severe liver disease

VI. Efficacy

  1. Per 1000 ACS patients, Ticagrelor prevents more adverse CV events than Clopidogrel
    1. Prevents 11 more cardiovascular deaths
    2. Prevents 11 more Myocardial Infarctions
    3. Prevents 6 more stent thromboses
  2. Majority of cardiovascular benefit is within first few weeks after Acute Coronary Syndrome
    1. Patients on Clopidogrel already will be unlikely to benefit from switch to Ticagrelor
    2. Discuss antiplatelet agent choice with cardiology at time of Acute Coronary Syndrome

VII. Adverse Effects

  1. Gastrointestinal Bleeding
    1. Similar bleeding risk to Clopidogrel
  2. Dyspnea
    1. Occurs with Brilinta use for 1 in 27 patients
  3. Dizziness or Syncope
  4. Acute Kidney Injury
  5. Other less common adverse effects
    1. Angioedema or Hypersensitivity
    2. AV Block
    3. Bradycardia
    4. Skin rash

VIII. Safety

  1. Pregnancy Category C
  2. Unknown safety in Lactation

IX. Drug Interactions

  1. Metabolized by CYP3A4
  2. Digoxin
  3. Morphine (and presumed other Opioids)
    1. Morphine decreased (35%) and delayed (2 hours) Ticagrelor absorption
    2. May affect acute STEMI management
    3. Kubica (2016) Int J Cardiol 215:201-8 [PubMed]
  4. Aspirin
    1. Doses >100 mg decrease Ticagrelor efficacy
  5. CYP3A4 Inhibitors (increased Ticagrelor effects and bleeding risk)
    1. Protease Inhibitors
    2. Clarithromycin
    3. Ketoconazole, Itraconazole or Voriconazole
  6. CYP3A4 Inducers (decreased Ticagrelor efficacy)
    1. Carbamazepine
    2. Phenobarbital
    3. Phenytoin
    4. Dexamethasone
    5. Rifampin
  7. Statins (e.g. Simvastatin, Lovastatin at doses >40 mg/day)
    1. Increased Statin related adverse effects

X. Management: Reversal

  1. See Platelet ADP Receptor Antagonist
  2. Stop 5 days before elective surgery

XI. References

  1. (2012) Presc Lett 19(5): 27
  2. Hamilton (2020) Tarascon Pocket Pharmacopoeia
  3. Filler and Lovecchio (2017) Crit Dec Emerg Med 31(7): 24
  4. Switaj (2017) Am Fam Physician 95(4): 232-40 [PubMed]

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Related Studies

Cost: Medications

brilinta (on 1/1/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
BRILINTA 60 MG TABLET $6.81 each
BRILINTA 90 MG TABLET $6.79 each
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

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