2 The technology

Description of the technology	Ticagrelor (Brilique, AstraZeneca) is an oral antagonist of the P2Y12 adenosine diphosphate receptor that inhibits platelet aggregation and thrombus formation in atherosclerotic disease.
Marketing authorisation	Ticagrelor 60 mg twice daily, co‑administered with aspirin (acetylsalicylic acid), has a marketing authorisation for 'the prevention of atherothrombotic events in adult patients with a history of myocardial infarction of at least 1 year and a high risk of developing an atherothrombotic event'. The marketing authorisation for preventing atherothrombotic events in adults with a history of myocardial infarction and a high risk of an atherothrombotic event was granted in February 2016. NICE's technology appraisal guidance on ticagrelor for the treatment of acute coronary syndromes covers ticagrelor 90 mg and aspirin for preventing atherothrombotic events.
Adverse reactions	Ticagrelor is contraindicated in patients with active pathological bleeding, a history of intracranial haemorrhage, or severe hepatic impairment. Co‑administration of ticagrelor with a strong CYP3A4 inhibitor (for example, ketoconazole, clarithromycin, nefazodone, ritonavir or atazanavir) is also contraindicated. The most commonly reported adverse effects include dyspnoea, epistaxis, gastrointestinal haemorrhage, subcutaneous or dermal bleeding, and bruising. For full details of adverse reactions and contraindications, see the summary of product characteristics.
Recommended dose and schedule	Ticagrelor 60 mg twice daily is the recommended dose when extended treatment is needed for patients with a history of myocardial infarction of at least 1 year and a high risk of an atherothrombotic event. Treatment may be started without interruption (continuation therapy) after the initial 1‑year treatment with ticagrelor 90 mg or other adenosine diphosphate (ADP) receptor inhibitor therapy in patients with acute coronary syndromes and with a high risk of an atherothrombotic event. Treatment can also be started up to 2 years from the myocardial infarction, or within 1 year after stopping previous ADP receptor inhibitor treatment. Unless contraindicated, ticagrelor should always be given with a daily low maintenance dose of aspirin 75 mg to 150 mg. There are limited data on the efficacy and safety of ticagrelor beyond 3 years of extended treatment.
Price	Ticagrelor costs £54.60 for a 56‑tablet pack (28 days' supply). Costs may vary in different settings because of negotiated procurement discounts.