临床药师参与宫颈癌合并慢性乙型肝炎患者化疗后肝功能异常治疗的药学监护

Pharmaceutical care of clinical pharmacists participating in abnormal liver function treatment of patient with cervical cancer and chronic hepatitis B after chemotherapy

目的探讨宫颈癌合并慢性乙型肝炎(CHB)患者化疗后肝功能异常的药物治疗方案及药学监护要点。方法选择2016年4月19日,因"宫颈癌ⅡB期接受2个周期化疗后24d,计划进行第3个周期化疗",于四川省肿瘤医院接受治疗的1例宫颈癌合并CHB患者为研究对象。病例收集医院临床药师参与本例患者治疗方案的制定。采用回顾性分析方法,采集本例患者的一般临床病例资料。对临床药师利用循证医学思维,从患者肝功能异常病因分析、药物治疗方案制定、药学监护等方面,协助临床医师制定有效治疗方案,进行分析和总结。结果 (1)病史采集结果:本例患者既往有CHB疾病史,未接受任何治疗。于四川省肿瘤医院进行第1、2个周期化疗前,肝功能检查结果正常;进行第3个周期化疗前,乙型肝炎5项检查结果显示乙型肝炎e抗原(HBsAg)、乙型肝炎病毒e抗体(HBeAb),乙型肝炎病毒核心抗体(HBcAb)均呈阳性,肝功能检查结果显示患者存在重度肝功能损害。(2)临床药师考虑本例患者肝功能异常系化疗药物导致的严重药物性肝损伤,化疗后乙型肝炎病毒(HBV)再次激活所致,建议临床医师暂停对患者的化疗,对其使用解毒类保肝药物还原型谷胱甘肽、抗炎类保肝药物异甘草酸镁、降丙氨酸氨基转移酶(ALT)与门冬氨酸氨基转移酶(AST)类药物双环醇片联合治疗,待患者肝功能稳定或好转后,可改为使用抗炎类保肝药物和必需磷脂类药物治疗。同时,建议临床医师对患者进行HBV DNA检查,并根据患者HBV DNA载量,给予核苷类药物抗病毒治疗。最终,临床医师采纳临床药师的相关建议。经临床保肝及抗HBV治疗后,本例患者肝功能恢复,排除化疗禁忌证后,继续采用第1、2个周期化疗方案进行第3个周期化疗,并且顺利完成第3个周期化疗。结论对于宫颈癌合并CHB的化疗患者,临床应重视对其进行肝功能及HBV监测,合理使用保肝及抗HBV药物。临床药师应根据该病患者病情与化疗药物特点,分析相关药物治疗风险,协助临床医师制定最优的个体化疗方案。

Objective To explore drug treatment and pharmaceutical care of clinical pharmacists participating in abnormal liver function treatment of patient with cervical cancer and CHB（CHB）after chemotherapy.Methods A case of patient with cervical cancer and chronic hepatitis B after chemotherapy who hospitalized in Sichuan Cancer Hospital due to ＂cervical cancerⅡB,24 days after two cycles of chemotherapy and planning to accept the third cycle of chemotherapy＂ in April 19,2016 was selected as research subject.Clinical pharmacists in Sichuan Cancer Hospital participated in the development of the patient′s treatment protocol.The clinical data of this patient was collected by retrospective method.How the clinical pharmacists help clinicians developing effective treatment protocol through analysis of the causes of abnormal liver function,development of drug treatment protocol,pharmaceutical care with the use of evidence-based medical thinking were analyzed and summarized.Results（1）History-taking results were as follows.This patient had a history of CHB and had not received any treatment.Before the first and second cycle of chemotherapy in Sichuan Cancer Hospital,her liver functions were normal.The hepatitis B surface antigen（HBsAg）,hepatitis B virus e antibody（HBeAb）and hepatitis B virus core antibody（HBcAb）all were positive before receiving the third cycle of chemotherapy,and the liver function examination indicated that the patients had severe liver function injury.（2）The clinical pharmacists considered the abnormal liver function was caused by reactivation of hepatitis B virus（HBV）after chemotherapy,and suggested that the clinicians should suspend chemotherapy and use reduced glutathione,anti-inflammatory magnesium isoglycyrrhizinate and bicyclol tablets which could reduce the levels of alanine transaminase（ALT）and aspartate aminotransferase（ALT）to protect the patient′s liver functions,then change to antiinflammatory drugs and essential phospholipids after liver functions being stable or normal.At the same time,the clinical pharmacists suggested that the clinicians should examine the patient′s HBV DNA and give nucleoside antivirus treatment according to the HBV DNA load.The clinicians adopted the recommendations of clinical pharmacists.After receiving the positive treatments,the liver functions of the patient was recovered,as the chemotherapy contraindication was eliminated,the third cycle of chemotherapy was successfully completed and the chemotherapy treatment was the same as the first and second cycles of chemotherapy.Conclusions For patients with cervical cancer and CHB undergoing chemotherapy,the liver functions and HBV monitoring should be emphasized,and the liver-protective and anti-HBV drugs should be used properly.The clinical pharmacists should analyze the risks of related medicinal treatments and assist clinicians to develop optimal chemotherapy protocol according to the patient′s condition and the characteristics of chemotherapy drugs.