从1例INR未达标颅内出血死亡的肺栓塞患者探讨老年患者华法林的合理使用

Analysis of rational use of warfarin in elderly patients based on a patient with pulmonary embolism who died of intracranial hemorrhage with substandard INR

1例71岁老年男性患者,因确诊"肺栓塞,高危"入院。入院后给予达肝素钠注射液片(5000 iu,ih,q 12 h)、阿司匹林肠溶片(100 mg,qd)、阿托伐他汀钙片(20 mg,qn),入院第3天将阿司匹林肠溶片换为华法林片(3 mg,qd)。每间隔3 d连续监测INR均低于目标值(INR 2～3),入院第7天华法林剂量加至4.5 mg,入院第10天华法林加至6 mg,第2次加量后第2天患者出现颅内出血转入心脏监护室,停用华法林和低分子肝素,并进行对症冶疗,患者最终抢救无效,于入院第14天死亡。临床药师参与了整个抢救过程,并对患者进行全程药学监护,严密监测停药后INR变化,并组织神经内科医生、心脏科医生和临床药师们讨论分析华法林导致颅内出血严重不良反应的原因以及老年患者在华法林使用过程中剂量的调整、与肝素的桥接以及出血的评估和拮抗,为预防老年患者服用华法林致颅内出血提供参考依据,旨为促进老年患者合理使用华法林。

A 71-year-old male patient was admitted to hospital with a diagnosis of pulmonary embolism and high risk. After admission, dalteparin sodium injection (5000 iu, ih, q 12 h), aspirin enteric-coated tablets (100 mg, qd) and atorvastatin calcium tablets (20 mg, qn) were given to him. Aspirin enteric-coated tablets was replaced by warfarin tablets (3 mg, qd) on the 3rd day. Results of continuous monitoring every 3 days showed that INR was lower than the target value (INR 2 – 3). So the dose of warfarin was added to 4.5 mg on the 7th day and then to 6 mg on the 10th day. Two days later, the patient developed intracranial hemorrhage and transferred to the cardiac intensive care unit. Warfarin and low molecular weight heparin were stopped immediately. But the patient was died on the 14th day. Together with neurologists and cardiologists, clinical pharmacists participated in the rescue process, closely monitored INR after discontinuation, investigated key points for rational use of warfarin including possible causes of intracranial hemorrhage induced by warfarin, dose adjustment of warfarin in elderly patient, bridge therapy with heparin, evaluation and antagonism of bleeding.