1例依诺肝素钠致肝损伤的药学监护实践

Pharmaceutical Care of a Patient of Liver Injury Induced by Enoxaparin Sodium

目的 探讨临床药师在药物性肝损伤(DILI)治疗中的药学监护作用。方法 1例系统性红斑狼疮(SLE)并肠系膜血管炎患者入院第6天,肝功能指标出现异常[其中丙氨酸氨基转移酶(ALT)> 1.5倍参考值上限(ULN),γ-谷氨酰转肽酶(GGT)> 3 ULN],临床药师经查阅文献和分析病例资料后判断DILI为依诺肝素钠所致可能性大,为混合型、急性,建议换服阿司匹林片(100 mg,口服,每天1次)预防血栓,加用异甘草酸镁(200 mg,静脉滴注,每天1次)+多烯磷脂酰胆碱(20 mL,口服,每天1次)+熊去氧胆酸(250 mg,口服,每天2次)护肝。入院第9天,将激素换为甲泼尼龙琥珀酸钠(120 mg,静脉滴注,每天1次);第12天,停用熊去氧胆酸;第14天,甲泼尼龙琥珀酸钠减量为80 mg,用法不变;第17天,停用异甘草酸镁。结果 医师采纳药师建议,入院第23天,患者肝功能指标逐渐恢复正常,予以出院。结论 临床药师参与DILI的用药治疗和药学监护,有助于判断其发生的可能性,还可优化治疗方案,促进合理、安全用药。

Objective To investigate the role of clinical pharmacists in pharmaceutical care during the treatment of drug-induced liver injury(DILI).Methods On the sixth day of admission,the liver function indexes of a patient with systemic lupus erythematosus(SLE)and mesenteric vasculitis were abnormal[alanine aminotransferase(ALT)>1.5 times the upper limit of normal(ULN),glutamyltranspeptidase(GT)>3 times ULN).After searching the literature and analyzing the case data,the clinical pharmacist evaluated that the possibility of DILI induced by enoxaparin sodium was high,and the DILI was mixed and acute.The pharmacist suggested that the patient took Aspirin Tablets(100 mg,oral administration,once a day)to prevent thrombosis,add magnesium isoglycyrrhizinate(200 mg,intravenous infusion,once a day)+polyene phosphatidylcholine(20 mL,oral administration,once a day)+ursodeoxycholic acid(250 mg,oral administration,twice a day)to protect the liver.On the 9th day of admission,the hormone was replaced with methylprednisolone sodium succinate(120 mg,intravenous drip,once a day).On the 12th day,ursodeoxycholic acid was stopped.On the 14th day,the dosage of methylprednisolone sodium succinate was reduced to 80 mg,and the usage remained unchanged.On the 17th day,magnesium isoglycyrrhizinate was stopped.Results The doctor accepted the pharmacist's suggestion.On the 23rd day of admission,the liver function indexes of the patient gradually returned to normal and he was discharged.Conclusion The participation of clinical pharmacists in medication and pharmaceutical care of DILI is helpful to judge the possibility of its occurrence,optimize the treatment plan and promote the rationality and safety of medication.