临床药师开展慢性肾脏病患者的药物重整实践

Practice of Clinical Pharmacist Participating in Medication Reconciliation for Patients with Chronic Kidney Disease

目的:为临床药师开展慢性肾脏病(CKD)药学服务提供参考。方法:以2019年1月1日-9月30日收入或转入我院肾内科的诊断为CKD的住院患者为研究对象,由临床药师主导,通过药学问诊、查看病历、分析总结药物相关问题并进行药物重整,向医师提出药物重整建议,为患者提供重整后用药清单并进行用药教育。结果与结论:共获得130例CKD患者的用药情况,临床药师对其中85例进行了药物重整,重整率为65.38%,85例患者涉及193条医嘱,其中占医嘱比例居前3位的药物相关问题分别是用法用量不适当(41.96%)、药物相互作用(18.13%)、药物选用不适当(14.51%);居前3位的重整药物类别分别为心血管系统类药物(26.94%)、纠正矿物质及骨代谢异常的药物(22.28%)、抗菌药物(16.02%)。临床药师的重整方案以改药(71例,36.78%)、停药(42例,21.76%)和加药(35例,18.13%)为主,其次为更改服药时间、调整剂量,多数(88.08%)被医师和患者接受。临床药师通过药物重整,可减少药物相关问题的发生。鉴于CKD患者多数年龄较大、并发症多、服药种类多,且部分药物因患者肾功能改变需进行剂量调整,故临床药师开展CKD患者的药物重整时应重点关注用法用量问题,特别是心血管系统类药物、纠正矿物质及骨代谢异常的药物,协助医师最大程度地保证患者用药安全。

OBJECTIVE:To provide reference for developing pharmaceutical care of chronic kidney disease(CKD)by clinical pharmacists.METHODS:During 1st,Jan.to 30th,Sept.in 2019,inpatients diagnosed as CKD admitted or transferred to nephrology department of our hospital were selected.Medication reconciliation was conducted by clinical pharmacists after pharmaceutical consultation,reviewing medical records,analyzing and summarizing drug-related problem(DRP).Medication reconciliation recommendations were proposed to physician.Subsequently,drug list and medical education were provided to patients by clinical pharmacists.RESULTS&CONCLUSIONS:The medication information of 130 patients was collected,and 85 of them were provided with medication reconciliation by clinical pharmacist,with a reconciliation rate of 65.38%.There were 193 medical orders involved 85 patients.Among all the DRP,the top three of proportion in medical orders were improper drug usage and dosage(41.96%),drug interactions(18.13%)and improper drug selection(14.51%).Among drugs related to medication reconciliation,top three types were cardiovascular system drugs(26.94%),drug correcting mineral and bone metabolism disorder(22.28%)and antibacterial drugs(16.02%).The main plans of medication reconciliation were drug change(71 cases,36.78%),drug withdrawal(42 cases,21.76%),drug supplement(35 cases,18.13%),followed by change of medication time and dosage adjustment.The majority(88.08%)of the recommendations were accepted by physician and patients.Clinical pharmacists can reduce the occurrence of DRP by medication reconciliation.The majority of patients with CKD were elderly and complicated with multiple diseases and took various drugs,and part of drugs required dose adjustment due to the change of kidney function,therefor clinical pharmacists implementing medication reconciliation to CKD,should pay attention to drug usage and dosage,especially cardiovascular system drug,drug correcting mineral and bone disorder,and assist physicians to ensure safety of drug use in patients.