临床药师参与1例下肢静脉血栓伴肺动脉血栓栓塞症患者华法林个体化抗凝治疗方案的病例分析
摘 要 目的 :探討临床药师在下肢静脉血栓伴肺动脉血栓栓塞症患者华法林个体化抗凝治疗中的作用。方法:临床药师参与1例下肢静脉血栓伴肺动脉血栓栓塞症患者的华法林个体化抗凝治疗过程,建议检测患者基因类型,并根据其基因检测结果[细胞色素P450(CYP)2C9*1*1和维生素K环氧化物还原酶复合体亚单位1(VKORC1)1399AA]及美国FDA推荐剂量,结合其生活习惯、身高和体质量等确定华法林初始剂量(3.125 mg,每日1次),再根据华法林药物基因组学联合会建立的华法林维持剂量预测公式计算华法林的维持剂量(2.5 mg和3.125 mg,每日1次,隔日交替剂量服用);建议给予对华法林影响较小的氟氯西林钠注射液剂量频次治疗,并行国际标准化比值、凝血酶原时间等相关参数及出血事件监测等药学监护。结果:医师采纳临床药师的建议,2.5 mg和3.125 mg,每日1次,隔日交替剂量服用,建议给予对华法林影响较小的氟氯西林钠注射液剂量频次治疗。患者恢复良好,准予带药出院。结论:临床药师基于药物基因组学参与患者华法林个体化抗凝方案的制定,可促进患者国际标准化比值的提高,降低其术后早期血栓栓塞及出血风险,进一步确保了患者用药安全、有效。
关键词 华法林;药物基因组学;个体化抗凝;临床药师;下肢静脉血栓;肺动脉血栓栓塞症
Case Analysis of Clinical Pharmacists Participating in Warfarin Individualized Anticoagulation Therapy for a Patient with Lower Extremity Venous Thrombosis Complicated with Pulmonary Arterial Thromboembolism
DENG Mingying,ZHANG Lei,FENG Xiaojun,SHI Tianlu,JIANG Ling(Dept. of Pharmacy, the First Affiliated Hospital, University of Science and Technology of China/Anhui Provincial Hospital, Hefei 230001, China)
ABSTRACT OBJECTIVE: To investigate the role of clinical pharmacists in the individual anticoagulation of warfarin for the patients with lower extremity venous thrombosis (LEVT) and pulmonary arterial thromboembolism (PATE). METHODS: Clinical pharmacists participated in individual anticoagulation of warfarin for the patients with LEVT and PATE. It was suggested to detect the gene type of...
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