Ticagrelor (Virata, Anplag, Brilinta) is a novel platelet inhibitor that has been recently introduced in Pakistan by Pharmevo PVT and CCL Pharmaceuticals. It binds to the ADP-receptors inhibiting the aggregation of platelets. Antiplatelets reduce the risks of cardiovascular deaths, myocardial infarction, and strokes. In aspirin-intolerant patients, it may be used in acute ST-elevation Myocardial infarction. It is also used in patients who have had angioplasty for the reduction of stent thrombosis.

Ticagrelor vs Clopidogrel:

Compared to Clopidogrel (Lowplat, Plavix), ticagrelor is a reversible inhibitor of platelets. It has a rapid onset of action and a short half-life. Furthermore, it is not a prodrug and does not require activation by the liver. It is more potent than clopidogrel and hence, associated with more bleeding especially when given in combination with aspirin, warfarin, heparin, or other anticoagulants. Apart from bleeding risks, it is associated with unexplained dyspnea and ventricular ectopics.

Ticagrelor in Pakistan is available as 60 mg and 90 mg tablets.

The usual dose of ticagrelor in patients with ST-elevation, non-ST elevation myocardial infarction, and post angioplasty is 180 mg as a loading dose, followed by 90 mg ticagrelor twice daily. Patients who are at risk of bleeding may be given 60 mg ticagrelor twice daily. The dose should be reduced to 60 mg twice daily after one year of dual antiplatelet therapy. Patients with a drug-eluting stent may be given ticagrelor for six months only. When switching from clopidogrel to ticagrelor, ticagrelor should be initiated 24 hours after stopping clopidogrel. A loading dose in such cases is not required, however, those in the acute stage of an acute coronary syndrome may be given the loading dose. The dose should also be reduced in liver disease. In severe hepatic impairment, it should be avoided.

When should ticagrelor be avoided?

Ticagrelor should be avoided in patients with hypersensitivity to the drug, those with active bleeding such as peptic ulcer bleeding and intracranial bleeding. It should not be used with strong CYP3A4 inhibitors like ketoconazole, clarithromycin, ritonavir, atazanavir, and nefazodone. It should also be avoided in patients with severe hepatic impairment. Other serious conditions that may be associated with its use include:

• thrombotic thrombocytopenic purpura
• bradyarrhythmias
• hyperuricemia
• dyspnea
• increased creatinine.

How to take ticagrelor tablets?

It may be administered without regard to meals. Patients who can not swallow the tablet may crush it and mix it with water to make a suspension. It may then be given as sips or via a nasogastric tube. If a dose is missed, taking a double dose should be avoided. The tablet should be taken at the next scheduled time.

Cost and brands of Ticagrelor in Pakistan:

Ticagrelor in Pakistan costs about 54 Rupees per tablet. It is currently marketed by Pharmevo PVT by the brand names of Tablet Anplag 60 mg and Tablet Anplag 90 mg. CCL Pharmaceuticals has marketed ticagrelor by the brand name of Tablet Virata 60 mg and Tablet Virata 90 mg. Before the markets flood with ticagrelor, the price of ticagrelor will probably remain high @ more than 50 Rupees per tablet.