氯吡格雷与瑞格列奈相互作用致低血糖的药学监护

Pharmacological monitoring of hypoglycemia caused by interaction between clopidogrel and repaglinide

1例49岁男性2型糖尿病、糖尿病肾病患者长期口服瑞格列奈3次/d,早1 mg、午2 mg、晚1 mg。因突发急性脑梗死加用氯吡格雷,用药第4天患者空腹血糖降至2.6 mmol/L。考虑为氯吡格雷与瑞格列奈相互作用致瑞格列奈血药浓度升高,从而造成患者出现严重低血糖,临床药师建议停用瑞格列奈,采用胰岛素治疗。医师将瑞格列奈减量为2次/d,早1 mg、午0.5 mg,3 d后患者空腹血糖波动在4.0~4.5 mmol/L。因患者有糖尿病肾病,肾功能不全可能增加低血糖风险,停用瑞格列奈,选用谷赖胰岛素3 U餐前皮下注射,并严密监测血糖。换用胰岛素治疗后患者空腹血糖波动在4.9~5.4 mmol/L。

A 49-year-old male patient with type 2 diabetes mellitus and diabetic nephropathy received long term use of retaglinide thrice daily orally,1-mg in the morning,2-mg in the afternoon and 1-mg in the evening.Because of the sudden acute cerebral infarction,clopidogrel was added,on the 4th day of the medication,the fasting blood glucose in the patient decreased to 2.6-mmol/L.It was considered that the interaction of clopidogrel and repaglinide caused the increase of repaglinide plasma concentration,which resulted in severe hypoglycemia in the patient.Clinical pharmacist suggested stopping repaglinide and using insulin.The physician reduced the dosage of repaglinide to twice daily,1-mg in the morning and 0.5-mg in the afternoon,and after 3 days the patient′s fasting blood glucose fluctuated between 4.0 and 4.5-mmol/L.Since the patient had diabetes nephropathy and renal insufficiency,which might increase the risk of hypoglycemia,repaglinide was stopped,and insulin glutamine 3 U was injected subcutaneously before meals,at the same time blood glucose was closely monitored.Fasting blood glucose fluctuated between 4.9 and 5.4-mmol/L after insulin treatment.