Ticagrelor (Brilique): breathlessness, bleeding and use with aspirin

Ticagrelor is an antiplatelet medicine. It reduces platelet clumping, which lowers the chance of another clot forming in a coronary artery. In the Brilique leaflet it is described as being used together with aspirin to reduce the risk of heart attack, stroke or death from cardiovascular causes in adults who have had a heart attack or unstable angina.

Because it works with aspirin, the two are normally taken together. The leaflet gives the aspirin dose as between 75 and 150mg a day, set by your doctor. Do not drop either one on your own initiative.

The leaflet describes a starting dose of two tablets together, a loading dose of 180mg, usually given in hospital, then one 90mg tablet twice a day for up to 12 months. Your doctor decides on the length. You can take it with or without food, at the same times every day. The blister pack has sun and moon symbols to help you identify morning and evening doses.

If you cannot swallow the tablet whole, the leaflet describes crushing it into a fine powder, mixing it with half a glass of water, drinking it at once and rinsing the glass with another half glass of water, which you also drink. If you miss a dose, take your next dose at the normal time and never double up.

The leaflet says not to take ticagrelor if you are allergic to it or its ingredients, are bleeding now, have had a stroke caused by bleeding in the brain, have severe liver disease, or take ketoconazole, clarithromycin, nefazodone, ritonavir or atazanavir.

Extra care applies if you have an increased bleeding risk from injury or surgery, a clotting condition, recent stomach or gut bleeding, a slow heart rate, asthma or breathing difficulties, liver problems or raised uric acid levels. Tell the clinician about all of these.

Shortness of breath is a very common side effect. The leaflet says it is usually mild, may appear early and can settle, but you should discuss it with your doctor. Other very common effects are high uric acid in the blood and bleeding. Common ones include bruising, headache, dizziness, diarrhoea, indigestion, nausea, constipation, rash, itching, nosebleeds, bleeding gums and, occasionally, signs of gout.

Get urgent care for signs of bleeding in the brain such as numbness, weakness, confusion, speech or walking difficulty and severe headache; for severe or prolonged bleeding, red or brown urine, vomit that looks like coffee grounds, black tarry stools or coughing up blood; for fainting; and for fever, purple skin spots, jaundice, extreme tiredness and confusion, which can signal a rare blood disorder called TTP.

The leaflet lists medicines to mention, including rosuvastatin, simvastatin or lovastatin at higher doses, rifampicin, phenytoin, carbamazepine, phenobarbital, digoxin, ciclosporin, quinidine, diltiazem, beta blockers, verapamil, morphine and other opioids, warfarin, anti-inflammatory painkillers, SSRIs, cisapride and ergot alkaloids.

Because of bleeding risk, tell doctors and dentists that you take ticagrelor before any operation. Never stop it before a procedure unless the team tells you to.

Ticagrelor is not recommended during pregnancy and women who could become pregnant should use contraception. If you are breastfeeding, discuss benefits and risks with your doctor. It is unlikely to affect driving, though you should avoid it if you feel dizzy or confused.

Suspected side effects can be reported to the MHRA through the Yellow Card scheme. Do not use tablets past their expiry date and return unwanted tablets to a pharmacist rather than binning them.