1例口服华法林患者PT-INR异常升高的病例分析和药学监护

Pharmaceutical care for a patient with PT-INR increased abnormally after taking warfarin

目的通过临床药师对1例风湿性心脏病二尖瓣置换术后患者服用华法林PT-INR异常升高分析和干预,探讨临床药师在抗凝药物治疗中个体化药学服务作用。方法通过详细的药学问诊,从影响华法林药动学和药效学角度,探讨了药物相互作用和疾病状态对华法林抗凝作用的影响机制。结果阿奇霉素和双氯芬酸钠是增加华法林抗凝作用的药物因素,腹泻的应激状态则加剧了这一作用,临床药师对患者进行了个体化的药学监护和用药教育。结论临床药师参与抗凝治疗的个体化药学服务,有利于促进抗凝药物的安全、合理使用。

Objective To explore the role of clinical pharmacists in the individualized anticoagulant therapy for a patient undergoing mitral valve replacement patient due to rheumatic heart disease, whose PT-INR increased abnormally after taking warfarin. Methods By asking detailed pharmaceutical questions, we explored the impact on pharmacokinetics and pharmacodynamics of warfarin, and the mechanism affecting warfarin anticoagulation by drug interactions and disease state. Results Azithromycin and diclofenac sodium were the drug factors enhancing the effect of warfarin anticoagulation, and emergency status of acute diarrhea was another factor to aggravate this effect. Conclusion The participation of clinical pharmacists ensures drug anticoagulant therapy to be safe and more rational.