卡瑞利珠单抗致免疫性心肌炎的用药监护

Medication care of immune myocarditis induced by camrelizumab

1例77岁男性肺癌患者在使用卡瑞利珠单抗联合化疗2个周期后,发现肌酸肌酶(CK)887 U/L,CK-MB 89μg/L,高敏肌钙蛋白I(hs-TnI)43750.1 ng/L;心电图检查示多导联ST段抬高。患者未进行第3个周期抗肿瘤治疗。临床药师参与会诊,协助医师分析患者用药情况,判断该不良事件与卡瑞利珠单抗的相关性为"可能"。患者被诊断为免疫性心肌炎G3级,给予甲泼尼龙1000 mg静脉注射、1次/d冲击治疗。临床药师协助医师查阅资料,制定糖皮质激素减量方案。冲击治疗2 d后减量为500 mg、1次/d,减量后患者心肌酶持续下降;3 d后减量为甲泼尼龙40 mg静脉注射、1次/12 h,连续应用7 d,患者hs-TnI降至2248.6 ng/L;改为泼尼松40 mg口服、2次/d。医嘱泼尼松减量方案:每周减量10~20 mg,每周监测心肌酶,减量至10 mg/d时,若心肌酶恢复正常再维持1~2周后停用。患者遵医嘱减量,顺利停药,未出现激素相关不良反应,未再出现心脏相关不适,未再行免疫治疗。

A 77‑year‑old male patient with lung cancer developed creatine kinase(CK)887 U/L,CK-MB89μg/L,andhigh-sensitivitytroponinI(hs‑TnI)43750.1 ng/L,andECGshowedmultileadST-segment elevation after 2 cycles of combination chemotherapy with camrelizumab.The patient did not undergo the 3rd cycle of anti‑tumor treatment.Clinical pharmacists participated in consultations and assisted physicians in analyzing the patient's medication.The causality between camrelizumab and the adverse event was considered as"possible"and the patient was diagnosed as immune myocarditis grade G3,receiving intravenous injection of 1000 mg methylprednisolone pulse therapy once daily.Clinical pharmacists assisted physicians in reviewing data and developing glucocorticoid reduction plans.The dosage was reduced to 500 mg once daily after 2 days of pulse therapy.The patient's myocardial enzymes continued to decrease after glucocorticoid reduction.After 3 days,the dosage of methylprednisolone was reduced to 40 mg by intravenous injection once every 12 hours for 7 days.The patient's hs‑TnI decreased to 2248.6 ng/L.Methylprednisolone was changed to prednisone 40 mg twice daily orally.The physician's advice for prednisone dose reduction:reduce the dosage by 10-20 mg per week,monitor myocardial enzymes every week,and when the dosage is reduced to 10 mg/d,and if the myocardial enzymes return to normal,maintain it for 1-2 weeks before discontinuation.The patient followed the doctor's advice and successfully stopped medication,and no glucocorticoid‑related adverse reactions and cardiac discomfort recurred.The patient did not receive immunotherapy again.