类风湿关节炎合并肺结核患者的药学监护

Pharmaceutical care on a patient with rheumatoid arthritis combined with tuberculosis

1例51岁女性患者,因胸闷、气短4个月,发热、咳嗽、咳痰3个月入院,诊断为左肺上下继发性肺结核、结核性心包炎、左下肺支气管扩张伴感染、肺动脉高压(轻度)、类风湿关节炎。患者入院后痰培养结果阴性,根据相关指南选择药物进行抗感染治疗,临床药师建议氟康唑首剂加倍;考虑到患者类风湿关节炎30年,建议将吡嗪酰胺更换为莫西沙星、利福平更换为利福喷丁,治疗5 d后患者咳嗽咳痰较前好转,未再发热。治疗期间,患者出现了甘油三酯、肝酶升高等不良反应,临床药师建议停用脂肪乳和葡萄糖注射液,停用后患者甘油三酯恢复正常,并建议停用保肝药。同时,临床药师对患者进行用药教育,主要包括抗结核的治疗原则、抗结核药物可能发生的ADR以及需要定期监测肝功能、血常规等。经对症治疗,患者病情好转出院。

One 51-year-old female patient was admitted to hospital with the pathogeny of chest tightness, shortness ofbreath for four months as well as fever, cough, expectoration for three months. The clinical diagnoses were secondary tuberculosisof left upper and lower lung, tuberculous pericarditis, left bottom lung bronchiectasis with infection, pulmonary hypertension （mild）,rheumatoid arthritis. After admission, sputum culture results of the patient was negative, anti-infectious drugs were administeredaccording to the guide. The clinical pharmacists recommended fluconazole for double of the first dose. Considering that the patientwith rheumatoid arthritis 30 years, clinical pharmacists suggested pyrazinamide replaced by moxifloxacin, rifampicin replaced byrifapentine. After five days treatment, the pathogeny of cough and expectoration of the patient relieved, and no fever occurred again.During the treatment, triglycerides and liver enzymes of the patient were elevated, clinical pharmacists recommended that the lipidand glucose injection should be stopped, and then triglycerides of patient reduced to normal with the drug withdrawal, and suggestedto stop using liver-protection medicine. At the same time, the clinical pharmacists provided medication education for the patientincluding antituberculosis treatment principle, possible adverse reactions of the drugs as well as monitoring of liver function andblood routine. Finally, the patient was discharged from the hospital with the symptomatic improvement.