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Antiplatelet (reversible P2Y12 inhibitor) Pregnancy: Avoid — limited data. LMWH preferred anticoagulation in ACS during pregnancy.

Ticagrelor

Brand names: Brilique

Adult dose

Dose: 180 mg loading then 90 mg twice daily (ACS); 60 mg twice daily (secondary prevention >1 year post-ACS)
Route: Oral
Frequency: Twice daily
Max: 180 mg loading; 90 mg twice daily
ACS (NSTEMI/STEMI with or without PCI): 180 mg loading, then 90 mg BD for 12 months with aspirin 75 mg OD. After 12 months: switch to 60 mg BD + aspirin (PEGASUS) for high-risk patients. PLATO trial: superior to clopidogrel (reduced MI and CV death).

Paediatric dose

Route: Not applicable
Frequency: Not licensed in children
Max: Not applicable
Not licensed in children.

Dose adjustments

Renal

No dose adjustment required.

Hepatic

Avoid in severe hepatic impairment.

Clinical pearls

  • Dyspnoea: occurs in ~14% — adenosine-mediated; NOT a sign of worsening HF; explain to patients proactively
  • Aspirin must be limited to 75–100 mg/day (higher doses reduce ticagrelor efficacy)
  • Direct-acting — no need for metabolic activation; no genetic resistance (unlike clopidogrel)
  • Stop 5 days before CABG (faster offset than prasugrel which needs 7 days)
  • PLATO trial: ticagrelor > clopidogrel in ACS (17% relative reduction in composite CV events)

Contraindications

  • Active pathological bleeding
  • History of intracranial haemorrhage
  • Severe hepatic impairment
  • Co-administration with strong CYP3A4 inhibitors (ketoconazole, clarithromycin)

Side effects

  • Dyspnoea (10–15% — adenosine-mediated; usually self-limiting; does NOT indicate pulmonary oedema)
  • Bleeding (GI, intracranial)
  • Bradycardia (Holter: ventricular pauses — usually asymptomatic)
  • Elevated creatinine and uric acid
  • Headache

Interactions

  • Strong CYP3A4 inhibitors — greatly increase ticagrelor levels (contraindicated)
  • Strong CYP3A4 inducers (rifampicin) — reduce ticagrelor efficacy (avoid)
  • Simvastatin/lovastatin >40 mg — increased statin toxicity
  • Digoxin — increased digoxin levels
  • Aspirin >100 mg/day — reduces ticagrelor efficacy

Monitoring

  • Dyspnoea
  • Bleeding signs
  • ECG (bradycardia risk)
  • Renal function

Reference: BNFc; BNF; PLATO trial; PEGASUS-TIMI trial; ESC NSTEMI/STEMI Guidelines. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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