临床药师对大剂量甲氨蝶呤排泄延迟致急性肾损伤伴癫痫发作患者的用药分析和监护

Medication Analysis and Care for Acute Renal Failure with Epileptic Seizure Cause by Excretion Delay of HD-MTX by Clinical Pharmacists

目的:探讨临床药师在大剂量甲氨蝶呤(HD-MTX,>1 g/m~2)排泄延迟致急性肾损伤(ARF)伴癫痫发作患者的治疗过程中的作用,为此类患者的合理用药及药学监护提供参考。方法:对1例中枢弥漫大B细胞淋巴瘤患者,给予HD-MTX进行化疗,于甲氨蝶呤给药后第2天开始发生因甲氨蝶呤排泄延迟导致的ARF。临床医师予调整亚叶酸钙解救剂量和给药频次进行治疗,效果不明显。临床药师通过查阅文献资料,结合患者病情分析甲氨蝶呤排泄延迟的原因,建议监测甲氨蝶呤血药浓度,加大碱化和水化力度,将静脉滴注碳酸氢钠液体量由125 mL增加至250 mL的同时,予患者口服碳酸氢钠片,并监测尿液pH值(保证尿液pH维持在7以上);嘱患者多饮水,保证每日尿量达到3 000~4 000 mL。甲氨蝶呤给药后44 h时,患者血药浓度为16.14μmol/L,属明显排泄延迟。甲氨蝶呤给药后第13天,患者出现癫痫大发作,临床医师予丙戊酸钠0.8 g,静脉滴注控制癫痫。临床药师对患者进行药学监护,发现患者口服碳酸氢钠片和丙戊酸钠片用药依从性不佳,故进行用药教育和药学监护;患者接受并按时服药。结果:医师采纳药师建议,监测甲氨蝶呤血药浓度,进行对症治疗。患者尿量增多,水肿减轻,血清肌酐逐渐恢复正常,肾功能逐渐恢复;癫痫症状得以控制。结论:在治疗HD-MTX排泄延迟致ARF伴癫痫发作的过程中,临床药师协助医师完善治疗方案,对患者进行药学监护和用药教育,保障了患者用药的安全合理。

OBJECTIVE:To investigate the role of clinical pharmacists in the treatment of delayed excretion of acute renal failure(ARF)with epileptic seizure caused by HD-MTX in a patient,and to provide reference for rational drug use and pharmaceutical care in such type of patients.METHODS:A patient with diffuse large B-cell lymphoma was given HD-MTX for chemotherapy,and ARF caused by delayed methotrexate excretion occurred on the second day after methotrexate administration.Clinical physicians adjusted the rescue dose and frequency of calcium folinate but the effect was poor.Clinical pharmacists analyzed the causes of delayed methotrexate excretion by reviewing literature and combining with the patient’s condition.It was suggested to monitor the blood concentration of methotrexate,strengthen alkalization and hydration,increase the volume of intravenous sodium bicarbonate from 125 mL to 250 mL,take Sodium bicarbonate tablets orally,and monitor the pH value of urine(pH value of urine maintained above 7).In addition,the pharmacist told the patient to drink water as much as possible to ensure the daily urine output reached 3000 to 4000 mL.The blood concentration of methotrexate was 16.14μmol/L 44 h after administration,which proved to be excretion delay.The patient had epileptic seizure on the 13th day after methotrexate medication.The physician gave sodium valproate 0.8 g intravenously to control epilepsy.The clinical pharmacist conducted pharmaceutical care for the patient,and found that the compliance of the patient taking Sodium bicarbonate tablets and Sodium valproate tablets orally was not good,so medication education and pharmaceutical care were conducted,then the patient accepted and took the drugs on time.RESULTS:The physician adopted the suggestions of the pharmacist to monitor the blood concentration of methotrexate and performed symptomatic treatment.The urine volume of the patient increased,the edema was reduced,serum creatinine gradually returned to normal,and renal function recovered gradually;the symptoms of epilepsy was controlled.CONCLUSIONS:In the treatment process of ARF complicated with epileptic seizure caused by excretion delay of HD-MTX,the clinical pharmacist assisted physician to improve the treatment plan and conducted pharmaceutical care and medication education for the patient,therefore ensure the safe and rational use of drugs.