临床药师参与1例华法林个体化抗凝治疗的药学实践

Individualized Anticoagulant Therapy for Warfarin in a Patient with Poor Metabolism

目的探讨临床药师在华法林个体化抗凝治疗中的作用。方法临床药师参与1例患者的华法林个体化抗凝治疗过程,根据指南建议停用阿司匹林,单用华法林治疗。根据基因检测结果调整华法林剂量,并随访行凝血酶原时间、国际标准化比值及有无出血事件发生等药学监护。结果医生接受临床药师建议,停阿司匹林,应用华法林1.25 mg/d,检查结果均在目标范围内,无出血和栓塞事件发生。结论临床药师通过基因检测指导华法林个体化给药,保障患者用药安全和有效,实现抗凝治疗的全程化、个体化、最优化。

Objective To investigate the role of clinical pharmacists in individualized anticoagulation therapy of warfarin.Methods The clinical pharmacist participated in the individualized anticoagulant treatment of warfarin in one patient.According to the guidelines,the clinical pharmacist recommend discontinuing aspirin and using warfarin monotherapy.The dose of warfarin was adjusted according to the genetic test results,the prothrombin time,INR and the occurrence of bleeding events and other pharmaceutical monitoring datas were followed.Results The doctor accepted the advice of clinical pharmacists,discontinued aspirin and warfarin 1.25mg/d was applied.The detection results were within the target range,no bleeding and embolic events occurred.Conclusion Clinical pharmacists guide individualized administration of warfarin through genetic testing to ensure the safety and effectiveness of medication for patients and realize the whole-process,individualization and optimization of anticoagulation therapy.