临床药师参与1例肺曲霉菌感染合并癫痫治疗药学实践

Pharmaceutical Practice of Clinical Pharmacist’s Participation in the Treatment of a Patient with Pulmonary Aspergillus Infection Complicated with Epilepsy

目的探讨临床药师参与药学实践对促进临床合理用药的作用。方法临床药师通过建议监测肺曲霉菌感染合并癫痫患者静脉序贯口服伏立康唑后的血药浓度,予以增加剂量和检测相关代谢酶的基因多态性,并分析抗感染疗效不佳的原因,参与临床治疗。结果第1次监测时伏立康唑体内血药浓度较低,临床药师建议将剂量加倍后仍较低;考虑受CYP2C19基因多态性影响,临床药师建议进行基因检测,但结果与血药浓度监测结果相悖;血药浓度偏低可能由卡马西平与伏立康唑间的相互作用所致,临床药师建议停用伏立康唑,改用卡泊芬净,临床症状明显改善。结论临床药师借助专业知识参与临床治疗,对患者进行药学监护,可促进临床合理用药。

Objective To investigate the role of clinical pharmacist’s participation in pharmaceutical practice in promoting clinical rational drug use.Methods The clinical pharmacist participated in the clinical treatment by monitoring the blood concentration of voriconazole in patients with pulmonary Aspergillus infection complicated with epilepsy after sequential oral administration of voriconazole,increasing dose and detecting the gene polymorphism of related metabolic enzymes,and analyzing the reasons for the poor efficacy of anti-infection.Results The blood concentration of voriconazole was low in the first monitoring,and was still low after the clinical pharmacist recommended doubling the dose.Considering its concentration was affected by the CYP2 C19 gene polymorphism,the clinical pharmacist recommended a genetic test.However,the results of the genetic test were contrary to the results of blood concentration monitoring.The low blood concentration of voriconazole might be caused by the interaction between carbamazepine and voriconazole.The clinical pharmacist recommended stopping voriconazole and switch to caspofungin,and then the clinical symptoms of the patient were significantly improved.Conclusion With the help of professional knowledge,the clinical pharmacist participates in clinical treatment and provide pharmaceutical care for patients,which can promote clinical rational drug use.