Ticagrelor for the treatment of acute coronary syndromes

Ticagrelor (Brilique, AstraZeneca) is an oral antagonist at the P2Y₁₂ adenosine diphosphate receptor, which inhibits platelet aggregation and thrombus formation in atherosclerotic disease. The summary of product characteristics (SPC) states that ticagrelor, co-administered with low-dose aspirin, is indicated for the prevention of atherothrombotic events in adult patients with ACS, defined as STEMI, NSTEMI or unstable angina. Patients with ACS who receive ticagrelor and aspirin may receive drugs only (medical management) or may also undergo revascularisation with PCI or CABG.

According to the SPC, treatment should be initiated with a loading dose of 180 mg ticagrelor (2 tablets of 90 mg) and then continued at 90 mg twice a day for up to 12 months. Patients taking ticagrelor should also take low-dose aspirin daily, unless specifically contraindicated. Following an initial loading dose of aspirin, the maintenance dose is 75 to 150 mg per day.

Ticagrelor is contraindicated in patients with active pathological bleeding, a history of intracranial haemorrhage, or moderate-to-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 reactions to treatment with ticagrelor include dyspnoea, epistaxis, gastrointestinal haemorrhage, subcutaneous or dermal bleeding, and bruising. For full details of adverse effects and contraindications, see the SPC.

The manufacturer stated in its submission that the cost of 90 mg tablets of ticagrelor is £54.60 for a pack of 56 tablets (28 days). Costs may vary in different settings because of procurement discounts.