心房颤动患者1例安全使用华法林的药学监护

Pharmaceutical care on the safe use of warfarin in a patient with atrial fibrillation

目的探讨临床药师在华法林安全使用中的作用。方法对1例心房颤动患者进行药学监护。患者入院第2天测凝血酶原时间(PT)33.5 s,国际标准化比值(INR)2.82;因感冒咳嗽加用复方甘草口服溶液,2 d后监测凝血四项显示PT升至38.4 s,INR升至3.38;临床药师分析患者所用药物中,复方甘草口服溶液可增强华法林的抗凝作用,建议停用华法林,行华法林基因多态性检测帮助确定华法林使用剂量。结果与结论患者INR值逐步回落,华法林调整至维持剂量每日2.5 mg。临床药师参与华法林相互作用的查找及个体化剂量的制定,保证患者的用药安全。

Objective To explore the role of clinical pharmacists in the safe usage of warfarin. Methods Clinical pharmacists provided pharmaceu- tical care for one patient with atrial fibrillation. The second day after hospi- talized, the prothrombin time （PT） and international normalized ratio （INR） of the patient were 33. 5 s and 2. 82. He took compound glycyrrhiza oral so- lution because of cold and cough. Two days later,the VF and INR increased to 38.4 s and 3. 38, respectively. Clinical pharmacists considered that compound glycyrrhiza oral solution could increase the anticoagulation of warfarin, and advised to stop rooking warfarin and use the detection of genetic polymorphism of warfarin to adjust the dosage. Results and conclusion The INR was decreased, and the dosage was decreased to 2. 5 mg once daily aceolding to the results of the detection. Clinical phamlacists participated in the searching for the interactions of warfarin and the formulation of warfarin individualized dose to ensure the safety of drug use.