临床药师参与1例心脏瓣膜置换术后肿瘤合并脑出血患者的抗凝治疗实践

Practice of anticoagulant therapy for a patient with tumor complicated with cerebral hemorrhage after heart valve replacement surgery participated by clinical pharmacists

心脏机械瓣膜置换术后患者需终身服用华法林。华法林与多种抗肿瘤药物存在药物相互作用,易发生药物不良反应,严重可导致脑出血。发生脑出血后,重启抗凝治疗的时机、抗凝治疗药物的遴选以及抗肿瘤治疗方案的制定是临床治疗的难点。本研究中,临床药师参与1例心脏瓣膜置术后乳腺癌患者合并脑出血、下肢静脉血栓的抗凝治疗药学实践。临床药师分析抗肿瘤药物卡培他滨与华法林存在药物相互作用可致患者脑出血。结合患者病情,协助医生制订新抗凝治疗方案,启动抗凝治疗并全程实施药学监护。抗凝期间未发生严重出血且下肢静脉血栓症状改善。通过探讨华法林与抗肿瘤药物的相互作用、抗凝治疗与药学监护重点,为心脏机械瓣置换术后肿瘤患者抗凝治疗提供临床参考。

Patients after mechanical heart valve replacement shall take warfarin for life.Warfarin has drug interaction with various anti-tumor drugs,which can easily lead to adverse drug reactions and even severe cerebral hemorrhage.After cerebral hemorrhage,the timing of restarting anticoagulant therapy,the selection of anticoagulant drugs and the form ulation of an anti-tumor treatment plan are the difficulties in clinical treatm ent.In this research,clinical pharmacists participated in the pharmaceutical practice of anticoagulant therapy for a patient with breast cancer complicated with cerebral hemorrhage and venous thrombosis of lower limbs after heart valve replacement.Clinical pharmacists believed that the drug interaction between capecitabine and warfarin could cause cerebral hemorrhage.Combined with the patient’s condition,they assisted the doctor in formulating a new anticoagulant therapy plan,started anticoagulant therapy and implemented pharmaceutical nursing throughout the process.No serious hemorrhage occurred during anticoagulant therapy and the symptoms of venous thrombosis of lower limbs were improved.By discussing the interaction between warfarin and antineoplastic drugs,as well as the key points of anticoagulant therapy and pharmaceutical nursing,we can provide clinical reference for anticoagulant therapy of tumor p atients after mechanical heart valve replacement.