临床药师参与1例华法林抵抗患者的抗凝治疗实践

Anticoagulant Experience of Clinic Pharmacists Participating in One Case of Patient with Warfarin Resistance

目的:探讨临床药师在心脏瓣膜置换患者华法林个体化抗凝治疗及抗凝管理中的作用。方法:临床药师参与胸心外科1例华法林抵抗患者抗凝治疗用药方案的制订及对患者进行抗凝指导和出院后抗凝随访。结果:临床药师依据基因检测对患者实施个体化抗凝治疗,建议医师将华法林剂量调整为5.625 mg/d,使国际标准化比值达到目标抗凝范围。患者在抗凝期间未发生严重的出血或血栓栓塞等不良事件。患者出院后,临床药师对其进行6个月抗凝随访,调整华法林抗凝方案,并使华法林剂量维持至8.125mg/d。结论:临床药师把握工作切入点,并且通过对患者住院及出院后实施全程化抗凝管理,充分体现临床药师的职业价值,也彰显临床药师在药物治疗团队的作用和地位。

OBJECTIVE：To explore the role of clinic pharmacists in warfarin individualized anticoagulant treatment and anticoagulant management in patients with cardiac valve replacement. METHODS：Clinic pharmacists participated in the determination of anticoagulant medication regimen for one case of patients with warfarin resistance and provided anticoagulant guidance and follow-up after discharge. RESULTS：Clinic pharmacists implemented individualized anticoagulant treatment based on gene detection,the physicians were suggested to adjust the warfarin dose to 5.625 mg/d to make international normal ratio（INR） into the target range. There were no serious adverse events such as hemorrhage or thrombosis during anticoagulation. After the patient＇s discharge,clinic pharmacists followed-up for 6-month anticoagulant and adjusted the regimen of warfarin anticoagulant. The dosage of warfarin was maintained to 8.125 mg/d. CONCLUSIONS：Clinical pharmacists grasp the starting point and implement the anticoagulation management of whole course during hospitalization and discharge to fully reflect the career value of the clinical pharmacists and also highlight the role and status of clinical pharmacists in drug treatment team.