临床药师全程化参与1例围产期肺栓塞患者联合使用华法林和阿司匹林抗凝的药学服务

Clinical Pharmacist Involved in the Integrated Pharmaceutical Care of Anticoagulant Treatment of a Perinatal Pulmonary Embolism Patient with Warfarin and Aspirin

目的探讨临床药师在围产期肺栓塞患者联合华法林和阿司匹林个体化抗凝治疗及抗凝管理中的作用。方法临床药师全程化参与心血管内科1例围产期肺栓塞患者抗凝治疗用药方案的制订及对患者进行抗凝监护和出院后随访。结果临床药师依据华法林基因检测对患者实施个体化抗凝调整,并在其出院后随访8个月,期间在医师同意下加用阿司匹林肠溶片,但患者INR仍未达标。为避免血栓事件的发生,更换为达比加群酯,用药2月余后,血栓消失。患者在抗凝期间未发生严重的出血或血栓栓塞等不良事件。结论临床药师通过对患者住院及出院后的抗凝实施全程化管理,为临床药师在药学服务模式的探索中提供参考,体现临床药师在患者药物治疗团队中的积极作用。

OBJECTIVE To investigate the role of clinical pharmacists in the individualized anticoagulant therapy and anticoagulant management of patients with perinatal pulmonary embolism with warfarin and aspirin.METHODS Clinical pharmacist participated in the formulation of anticoagulant treatment and medication plan of one perinatal pulmonary embolism patient in the department of cardiovascular medicine,with the anticoagulant guidance and follow-up after discharge.RESULTS According to the warfarin gene test,the clinical pharmacist carried out individual anticoagulation adjustment on the patient,and followed up for 8 months after discharge,during which aspirin enteric-coated tablets were added with the consent of the doctors,but the INR of the patient still failed to meet the standard.In order to avoid the occurrence of thrombus events,the enteric-coated tablets was replaced with dabigatran ester the thrombus disappeared after 2 months of administration.No serious bleeding or thromboembolic adverse events occurred during anticoagulation.CONCLUSION Clinical pharmacists carry out whole-process anticoagulation management for patients in hospital and after discharge to provide reference for clinical pharmacists in the exploration of pharmaceutical care model,and reflect the positive role of clinical pharmacists in patients’drug treatment team.