临床药师参与1例氟康唑致他克莫司血药浓度升高患者管理的药学监护

Medical monitoring of the participation of clinical pharmacists in a patient with the increased blood concentration of tacrolimus caused by fluconazole

1例52岁的肾移植术后男性患者因“肺隐球菌病”入住呼吸科病房。患者长期服用他克莫司、吗替麦考酚酯和甲泼尼龙抗排异治疗。在对患者给予氟康唑抗真菌治疗时发现,其他克莫司血药浓度明显升高。对此,临床药师提议,由于联用他克莫司和氟康唑治疗会使他克莫司血药浓度升高,故需调整他克莫司治疗的剂量方案并监测他克莫司血药谷浓度,而氟康唑治疗的剂量方案不应调整。提议获采纳后,患者的他克莫司血药谷浓度和真菌感染均得到良好的控制。

A 52-year-old man with kidney transplantation was hospitalized in the respiratory ward due to“pulmonary cryptococcosis”.The patient was treated with tacrolimus,mycophenolate mofetil and methylprednisolone for anti-rejection therapy.When antifungal treatment with fluconazole was given to the patient,it was found that the blood concentration of tacrolimus was significantly increased.Clinical pharmacists proposed that the dosage regimen for tacrolimus treatment should be adjusted and tacrolimus blood concentration should be monitored while the dose regimen for fluconazole treatment should not be adjusted because the combination of tacrolimus and fluconazole would increase the blood concentration of tacrolimus.This recommendation was accepted by clinicians and the valley concentration of tacrolimus and fungal infection were well controlled.