Ticagrelor

About Ticagrelor

Ticagrelor and its main metabolite bind reversibly to the P2Y12 receptor on platelets, which blocks platelet activation. The label covers three uses: lowering the risk of cardiovascular death, heart attack and stroke in acute coronary syndrome or after a heart attack; lowering the risk of a first heart attack or stroke in coronary artery disease at high risk of them, a benefit established in people with type 2 diabetes; and lowering the risk of stroke after an acute ischemic stroke with an NIH Stroke Scale score of 5 or less, or a high-risk TIA. After acute coronary syndrome it starts with a 180 mg loading dose, then 90 mg twice a day for the first year and 60 mg twice a day after that. Coronary artery disease without a past heart attack or stroke is treated with 60 mg twice a day, and after a stroke or TIA the loading dose is followed by 90 mg twice a day for up to 30 days. Aspirin is usually taken at 75 to 100 mg a day, although after percutaneous coronary intervention (PCI) the label lets the prescriber consider ticagrelor as the only antiplatelet drug, weighing the changing risks of clotting and bleeding. Safety and effectiveness in children have not been established.

The boxed warning says ticagrelor, like other antiplatelet drugs, can cause significant, sometimes fatal bleeding. It must not be taken with active bleeding, such as a bleeding peptic ulcer, by anyone who has ever had bleeding inside the skull, or by anyone allergic to it, and it is not started in people having urgent bypass surgery. Bleeding is managed without stopping ticagrelor when possible, because stopping raises the risk of later heart attack, stroke and death; before surgery with a major bleeding risk it is paused for five days when possible and restarted once bleeding is controlled. Bleeding and shortness of breath are the most common side effects; the label advises continuing ticagrelor through shortness of breath if possible, and considering another antiplatelet drug only if it becomes intolerable. It can also cause pauses in the heartbeat and slow rhythms, including heart block, and central sleep apnea, and it is avoided in severe liver impairment.

Strong CYP3A inhibitors raise its levels substantially and strong CYP3A inducers lower them substantially, so both are avoided, and opioids such as morphine delay and reduce its absorption. It is not taken with another oral P2Y12 blocker, although people can move from clopidogrel to ticagrelor without a gap in protection. The label advises against aspirin above 100 mg a day, since higher doses appear to make ticagrelor less effective, and breastfeeding is not recommended during treatment.

Taking Ticagrelor

How to take it

Twice a day at about the same times, with or without food, usually with daily low-dose aspirin unless the prescriber says otherwise. If you cannot swallow a tablet whole, crush it, mix it with water and drink the mixture right away. Do not stop taking it without talking to the prescriber.

If you miss a dose

Skip the missed dose and take the next one at its usual time. Do not take a double dose.

Storage

At room temperature, away from heat and moisture (not in the bathroom), out of reach of children. Use a take-back program rather than flushing.

Interactions to know about

Strong CYP3A inhibitors such as ketoconazole, itraconazole and clarithromycin, and strong inducers such as rifampin, phenytoin and carbamazepine, are avoided; ask about St. John’s wort. Keep aspirin to the dose prescribed, generally no more than 100 mg a day, and ask before taking ibuprofen or naproxen. Simvastatin and lovastatin above 40 mg a day and rosuvastatin above 20 mg a day are avoided, and digoxin levels are checked.

This summarizes the official prescribing information. Your prescriber’s and pharmacist’s instructions, and the leaflet that comes with your medicine, take priority.

Why the cash price for Ticagrelor differs from pharmacy to pharmacy

Generic ticagrelor now comes from many makers, so it is no longer priced only as a brand; quotes depend mostly on each pharmacy’s fee and markup and on whether ticagrelor is on its flat-price generic list. A prescription that names Brilinta and blocks substitution is filled with the brand and priced as one.

The change from 90 mg to 60 mg after the first year is a new prescription and fill, and a course after a stroke or TIA lasts up to 30 days, so the dispensing fee is a larger part of that quote.

Ways to pay less for Ticagrelor without insurance

• Ask for generic ticagrelor, and check that the prescription does not block substitution.
• Once you are on a steady dose, ask for a ninety-day supply, and compare more than one pharmacy.
• Ask the prescriber when your dose will change from 90 mg to 60 mg, so you do not buy more 90 mg tablets than you will use.
• After a stroke or TIA, ask for the exact quantity your course needs.
• Upload the prescription to Script Unlock so licensed pharmacies can quote their cash price. You pay the pharmacy directly.

Questions to ask your pharmacist about Ticagrelor

1. 1.How much aspirin should I take with it, and which other products contain aspirin?
2. 2.What should I do if I get short of breath or notice unusual bleeding?
3. 3.Do any of my medicines, such as my statin, an antibiotic or an antifungal, interact with it?
4. 4.Should I pause it before surgery or dental work, and who decides?

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