1例抗凝药物和抗结核药物合用的患者用药监护

A Case Study of Pharmaceutical Care on Combined Use of Anticoagulants and Anti-tuberculosis Drugs

目的探讨临床药师在下肢深静脉血栓形成合并肺结核患者个体化抗凝治疗方案的制订,新型口服抗凝药的选择、用药监护中的工作要点。方法参与1例下肢深静脉血栓合并肺结核患者的抗凝治疗用药方案的制订与用药监护。该患者既往服用华法林但不起效,临床药师从基因多态性、药物相互作用等方面寻找原因,重新为患者制订给药方案。结果确定适合患者的给药方案,患者抗凝达标后出院,临床药师从影响华法林疗效的各种因素,INR的监测等注意事项对患者进行用药教育,提高患者抗凝治疗依从性。结论抗凝药物个体化给药方案的制订和用药监护是临床药师开展药学服务的工作切入点。

OBJECTIVE To find out the essentials of clinical pharmacists＇ work on making individualized anticoagulation thera- py, tailored to patients with deep vein thrombosis and pulmonary tuberculosis, and on its pharmaceutical care. METHODS The clin- ical pharmacist participated in one case of individualized anticoagulation therapy and provided pharmaceutical care to one patient with deep vein thrombosis and pulmonary tuberculosis. The patient used to take warfarin, but the treatment was ineffective, therefore the clinical pharmacist tried to find out the reason from such aspects as interactions among genetic polymorphism, anticoagulants and anti- TB drugs, then adjusted the therapy for the patient. RESULTS A dosage regimen suitable for the patient was formulated, and medi- cation education was carried out to the patient in terms of medication instructions, such as influencing factors on curative effects of war- farin and monitoring of INR, to improve the patient compliance related to anticoagulation therapy. CONCLUSION Clinical pharma- cists should start pharmaceutical service right from making individualized anticoagulation therapy and carrying out pharmaceutical care.