运用《辅行诀》所载“汤液经法图”理论开展中药汤剂治疗消渴病的药学监护1例

Applying“Tangye Jingfa map”in Fuxingjue to Carry Out Pharmaceutical Care for One Diabetic Case using Traditional Chinese Medicine Decoction for the Treatment

目的基于《辅行诀》所载“汤液经法图”理论体系,对1例采用中药复方汤剂治疗的消渴病患者进行药学监护。方法患者为老年女性,患有糖尿病、高血压、冠心病等多种疾病,以口干、口渴15年,伴夜间血压升高10 d就诊。从患者入院开始纳入药学监护,采用“汤液经法图”所示的五脏虚实辨证和五味补泻治疗理论原则,确定患者的病因病机和治则治法,并分析每次临床处方的合理性。开展药学问诊,监护临床治疗的有效性和安全性,并适时提供药学建议。入院后辨为因脾虚痰壅所致的“消渴病,肺胃壅热证”,以半夏白术天麻汤合柴葛解肌汤加减治疗,服药9 d后(期间调方1次)虽然有部分效果,但主要症状(口干、汗出、咳嗽、头晕伴有手麻抽筋)均未改善,且患者出现“咳嗽时气不够用”的新问题。临床药师运用“汤液经法图”理论体系,判定该患者为肺虚合并肝实为主的虚实夹杂证,而“肺德在收,以酸补之、咸泻之;肝德在散,以辛补之、酸泻之”,故治疗上应以既能补肺同时又能泻肝的酸味药为主。前2次处方的配伍结构分别为“六苦三辛三咸三甘一酸”和“七苦三咸二甘二辛二酸”,均以苦味为主而酸味极少。医师与药师沟通后,第3次调整处方结构为“四酸四咸三苦三甘二辛”,以酸味药以及咸味药与苦味药的咸苦化酸为主,再服药5 d。结果患者临床症状明显改善,无不良反应表现。结论运用“汤液经法图”理论体系,开展以中药复方主导药味为切入点的药学干预是中药药学监护的一种有益的尝试。

Objective In this case,the theoretical system of the“Tangye Jingfa map”in Fuxingjue was used to carry out pharmaceutical care of one diabetic case with the coexistence of multiple diseases using Traditional Chinese Medicine Decoction.Methods The patient is an elderly woman with diabetes,hypertension,coronary heart disease and other diseases.The patient was presented with dry mouth and thirst for 15 years,and high nocturnal blood pressure for 10 days.The patient was brought into pharmaceutical care since the admission,the patient's etiology,pathogenesis,and treatments were determined by the theoretical system of the viscera deficiency and excess dialectic and five-flavor tonification and purgation therapy which presented in“Tangye Jingfa map”,and the rationality of each clinical prescription was analyzed.Pharmaceutical inquiry was carried out.The effectiveness and safety of clinical treatment were monitored,and the timely pharmaceutical advice was provided.After the admission,she was identified as the"diabetes,lung and stomach congestion heat syndrome"caused by spleen deficiency and phlegm accumulation.Patient was treated with Banxia Baizhu Tianma Decoction and Chaige Jieji Decoction,and part of symptoms was improved after taking the medicine for nine days(adjusting the prescription once during the period).However,the main symptoms were not improved,and there was a new problem of insufficient qi when coughing.The clinical pharmacist analysed that the patient was mainly lung deficiency combined with liver excess,and the deficiency and excess were mixed by using“Tangye Jingfa map”theoretical system.The treatment should be based on the sour medicine of invigorating lungs and purging liver.The first two prescriptions of drug structure were“six bitter,three pungent,three salty,and three gan acid”,“seven bitter,four salty,two gan,two pungent,one acid”,and these two prescriptions were mainly bitter,but rarely sour.However,the main clinical symptoms did not relief.After the communication with the clinical pharmacist,doctor adjusted the prescription structure in the third prescription as“four acid,four salty,three bitter,three sweet,and two acrid”,and the main effect of the prescription become invigorating lungs and purging liver.After taking the medicine for five days,dry mouth,bitter mouth,sweating,cough,dizziness,numbness,lower limbs,cramps.Results The clinical symptoms of the patients were obviously improved,and there were no adverse reactions.Conclusion This case suggests that using the theoretical system of“Tangye Jingfa map”in Fuxingjue to carry out pharmaceutical intervention with the dominant medicinal taste of Chinese medicine compound as the starting point is a feasible way for pharmaceutical care of traditional Chinese Medicine Decoction.