Ticagrelor (Ticagrelor)
Also sold as: Brilinta, Ticaday, Ticarelo
Pregnancy
Cat C
Lactation
Avoid
Schedule
H
Forms
Tablet 60mg +1
Indications
- Acute coronary syndrome — NSTEMI, STEMI (with aspirin — preferred over clopidogrel for ACS)
- Post-ACS maintenance — reduction of recurrent cardiovascular events
- Post-MI (extended duration — PEGASUS indication)
Adult Dosing
ACS (NSTEMI/STEMI) — loading dose
180 mg loading dose
Single loading dose on presentation
Loading dose given regardless of prior clopidogrel loading; faster and more consistent platelet inhibition than clopidogrel
ACS — maintenance (DAPT with aspirin)
90 mg BD
12 months (with aspirin ≤100 mg/day)
Aspirin dose MUST be ≤100 mg/day — higher aspirin doses reduce ticagrelor efficacy (PLATO trial finding); use pantoprazole for GI protection
Post-ACS extended maintenance (PEGASUS — beyond 12 months)
60 mg BD
Additional 12 months (after initial 12 months of 90 mg BD)
For patients ≥1 year post-MI without major bleeding; 60 mg BD dose used for extended phase; discuss risk-benefit carefully
Pediatric Dosing
No established paediatric indication or dosing
Renal Dose Adjustment
| CrCl / eGFR | Dose Adjustment |
|---|---|
| Any CrCl | No dose adjustment required — ticagrelor does not require renal dose adjustment; use with caution in severe renal impairment; dialysis patients: limited data |
Hepatic Adjustment
Contraindicated in severe hepatic impairment (Child-Pugh C) — significantly increased drug exposure and bleeding risk. Use with caution in moderate hepatic impairment. No adjustment required for mild impairment.
Pregnancy & Lactation
Pregnancy: Category C
Limited human data; animal studies show embryo-fetal toxicity. Use only when clearly indicated and benefits outweigh fetal risk. Avoid near term due to bleeding risk in neonate.
Lactation: Avoid
Unknown whether ticagrelor is excreted in human milk. Animal data suggests excretion. Avoid breastfeeding during treatment due to unknown risk to infant.
Top Drug Interactions
| Interacting Drug | Effect | Severity |
|---|---|---|
| Strong CYP3A4 inhibitors (ketoconazole, itraconazole, clarithromycin, ritonavir) | Markedly increase ticagrelor plasma levels — substantially increased bleeding risk; avoid combination; if azole antifungal required, use fluconazole (moderate inhibitor) with caution | Major |
| Rifampicin (and other strong CYP3A4 inducers) | Rifampicin reduces ticagrelor exposure by approximately 73% — significantly reduces antiplatelet efficacy; avoid combination; consider alternative antiplatelet agent if rifampicin essential | Major |
| Aspirin >100 mg/day | High-dose aspirin reduces ticagrelor's clinical efficacy — based on PLATO subgroup analysis; keep aspirin dose at ≤100 mg/day (75–100 mg OD) when using ticagrelor | Major |
| Digoxin | Ticagrelor inhibits P-glycoprotein — increases digoxin plasma levels by approximately 75%; monitor digoxin levels and for toxicity (bradycardia, nausea, visual changes) | Moderate |
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Side Effects
Common
- Dyspnoea (shortness of breath) — most distinctive side effect; usually mild, occurs at rest or on exertion, often transient; mechanism unclear (adenosine accumulation); does NOT represent bronchospasm or heart failure
- Bruising and bleeding tendency
- Epistaxis (nosebleeds)
- Dizziness
- Nausea
- Ventricular pauses and bradycardia (mostly asymptomatic in trials — Holter monitoring study finding)
Serious / Discontinue If
- Major bleeding — GI haemorrhage, intracranial haemorrhage
- Stent thrombosis on premature discontinuation (life-threatening)
- Significant bradycardia or ventricular pauses — use with caution in sick sinus syndrome or AV block without pacemaker
- Severe dyspnoea requiring drug discontinuation (minority of patients)
- Gout/hyperuricaemia (ticagrelor inhibits uric acid reabsorption)
Contraindications
- Active pathological bleeding
- History of intracranial haemorrhage
- Severe hepatic impairment (Child-Pugh C)
- Concurrent strong CYP3A4 inhibitors
- Hypersensitivity to ticagrelor
- Sick sinus syndrome, high-degree AV block without pacemaker (relative)
Available Indian Brands
| Brand | Manufacturer | Price (approx) |
|---|---|---|
| Brilinta 90mg | AstraZeneca | ₹185/14 tab |
| Ticaday 90mg | Sun Pharma | ₹145/14 tab |
| Ticarelo 90mg | Cipla | ₹155/14 tab |
Monitoring Required
- FBC and platelet count at baseline; monitor for bleeding signs
- Renal function and LFTs at baseline
- Monitor for dyspnoea — if new or worsening dyspnoea, evaluate and reassure; rarely requires drug withdrawal
- ECG/Holter if symptomatic bradycardia or syncope (ventricular pauses)
- Uric acid if gout history
- Review DAPT duration and aspirin dose at each cardiology visit
Patient Counseling Points
- Do NOT stop this medicine without talking to your cardiologist — stopping suddenly after a heart stent or heart attack greatly increases the risk of another cardiac event
- You may notice shortness of breath — this is a known side effect of this medicine and is usually harmless and temporary; tell your doctor but do not panic
- Take twice daily (morning and evening) — at the same times each day
- Keep aspirin dose LOW (75–100 mg) — do not increase aspirin on your own; higher aspirin doses can reduce how well this medicine works
- Avoid strong antifungal tablets like itraconazole or ketoconazole without doctor advice
- Tell ALL doctors and dentists that you are on ticagrelor before any procedure — especially if surgery is needed
- Report immediately: unusual bleeding (black stools, blood in urine, prolonged cut bleeding), severe shortness of breath, or dizziness/fainting
- Carry a medic alert card stating you are on antiplatelet therapy
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Clinically reviewed by: Dr. Priya Nair, DM (Cardiology), Interventional Cardiologist, Apollo Hospitals, Chennai
Last reviewed: 2026-04-30
References
- PLATO Trial — Wallentin L et al. N Engl J Med 2009;361:1045–57
- PEGASUS-TIMI 54 — Bonaca MP et al. N Engl J Med 2015;372:1791–800
- ESC Guidelines on Acute Coronary Syndromes, 2023
- Micromedex Drug Interactions — Ticagrelor, 2024
- BNF (British National Formulary) — Ticagrelor monograph, 2024