临床药师全程参与1例肝移植术后伴重度肾功能不全带状疱疹后神经痛患者的药学监护

The clinical pharmacist participated in the pharmaceutical care of a patient with severe renal insufficiency and post-herpetic neuralgia after liver transplantation

目的针对肝移植术后伴肾功能不全的带状疱疹后神经痛患者,疼痛专业临床药师协助临床医生为该患者选择最佳的镇痛药物治疗方案提供药学支持。方法疼痛专业临床药师全程参与了1例肝移植术后合并重度肾功能不全带状疱疹后神经痛患者的治疗,分析其肾功能不全的原因,协助其镇痛治疗方案的调整,并实施全程化的药学监护。结果疼痛专业临床药师根据患者的血清肌酐值推算出该患者为重度肾功能不全,推荐口服加巴喷丁0.3g qd,联合肝肾功能影响较小的丁丙诺啡透皮贴局部治疗,治疗5d后疼痛较前显著缓解、不影响睡眠,同时在疱疹区皮下注射消炎镇痛药,疼痛进一步缓解,复查肝肾功能较前有所好转,准予出院,瞩其出院后继续服用加巴喷丁稳固疗效、定期复诊。结论肝脏移植手术本身及后期的免疫抑制剂的使用,均可能导致该患者肝移植术后的肾功能不全。术后免疫抑制状态是带状疱疹发病的高危因素,对伴有肾功能不全的带状疱疹后神经痛患者,仍然可以选择加巴喷丁、普瑞巴林、曲马多、丁丙诺啡透皮贴等临床常用药物,但需严格根据肌酐清除率调整用量,必要时可联合微创介入治疗技术,对于带状疱疹高危人群建议在进行移植手术前接种水痘-带状疱疹疫苗。

Objective For post-herpetic neuralgia patients with renal insufficiency after liver transplantation,pain professional clinical pharmacists assist clinicians to provide pharmaceutical support for the patient to choose the best analgesic drug treatment.Methods The pain professional clinical pharmacists participated in the treatment of one patient with severe renal insufficiency post-herpetic neuralgia after liver transplantation,analyzed the causes of renal insufficiency and assisted the adjustment of analgesic treatment plan,and carry out full-process pharmaceutical care.Results According to the serum creatinine value of the patient,the pain professional clinical pharmacist calculated that the patient had severe renal insufficiency,and recommended oral gabapentin 0.3g QD,combined with buprenorphine transdermal patch with less effect on liver and kidney function.5 days after treatment,the pain was significantly relieved and did not affect sleep.At the same time,the pain was further relieved by subcutaneous injection of anti-inflammatory analgesics in the herpes area,the liver and kidney function was improved,and the hospital discharge was allowed.After discharge,he continued to take gabapentin to stabilize the curative effect and return to the hospital regularly.Conclusion The use of immunosuppressants in the liver transplantation itself and in the later stage may lead to renal insufficiency after liver transplantation.The state of postoperative immunosuppression is a high risk factor for the incidence of herpes zoster.For patients with post-herpetic neuralgia with renal insufficiency,commonly used clinical drugs such as gabapentin,pregabalin,tramadol and buprenorphine transdermal patch can still be selected.However,the dosage should be adjusted strictly according to the creatinine clearance rate,and if necessary,it can be combined with minimally invasive interventional therapy.It is recommended that people at high risk of shingles be vaccinated with varicella-zoster vaccine before transplant.