1例糖尿病合并心血管疾病患者的药物治疗管理

Medication therapy management of a diabetic patient complicated with cardiovascular disease

目的 为糖尿病合并心血管疾病患者的药物治疗管理(MTM)提供参考。方法 1例63岁男性糖尿病患者行冠状动脉介入术后因每日上午出现一过性头痛到我院神经内科就诊,并被推荐到药学门诊。药学门诊药师分析后认为,患者出现的头痛症状、严重便秘和高尿酸血症很可能与其所用药物有关;进一步发现患者血压、心率、血糖和血脂等动脉粥样硬化性心血管疾病影响因素均未达标。药师通过药学问诊与药品不良反应的判断、用药评估、药物重整、用药宣教和药学随访等为患者提供MTM服务。结果 药师经过13周15次的MTM服务,重整优化了药物治疗方案,停用了引起药品不良反应的药物单硝酸异山梨酯缓释片、硝苯地平控释片和吲达帕胺片,使患者用药品种数由15种调减至7种。患者头痛症状消失,严重便秘症状明显改善,血尿酸降至正常范围;血压、心率、空腹血糖、糖化血红蛋白、低密度脂蛋白胆固醇和尿酸等动脉粥样硬化性心血管疾病影响因素分别由MTM服务前的>140/90 mmHg(1 mmHg=0.133 kPa)、70~80次/min、7.71 mmol/L、7.2%、2.13 mmol/L和494μmol/L降至MTM服务后的<130/80 mmHg、55~60次/min、6.22 mmol/L、6.3%、1.55 mmol/L和348μmol/L。结论 药师为患者提供MTM服务,可提高患者生活质量和治疗效果,降低用药风险,提升医院药物合理应用水平和临床药学服务能力。

OBJECTIVE To provide reference for medication therapy management(MTM)of diabetic patients complicated with cardiovascular disease.METHODS A 63-year-old male diabetic patient who suffered from temporary headache every morning after percutaneous coronary intervention(PCI)visited the neurology department of our hospital,and then was recommended to the pharmaceutical outpatient department.The pharmacists thought that the patient’s symptoms of headache,severe constipation and hyperuricemia were more likely induced by the medication used.The pharmacists further found that his atherosclerotic cardiovascular disease(ASCVD)influencing factors such as blood pressure,heart rate,blood glucose and blood lipids did not reach standard.The pharmacists provided MTM services for the patient through pharmacy inquiry and adverse drug reactions judgement,medication evaluation,medication reconciliation,medication education and pharmacy follow-up.RESULTS Through fifteen MTM services for thirteen weeks,the pharmacists reconciliated and optimized the medication therapy plan,discontinued the use of Isosorbide mononitrate sustained-release tablets,Nifedipine controlled-release tablets,and Indapamide tablets,which caused adverse drug reactions;the number of drugs was adjusted from fifteen to seven,and the symptom of headache disappeared;severe constipation had also been significantly improved,and hyperuricemia dropped to normal range.The ASCVD influencing factors of blood pressure,heart rate,fasting plasma glucose,glycosylated hemoglobin,low-density lipoprotein cholesterol and uric acid were reduced from>140/90 mmHg(1 mmHg=0.133 kPa),70-80 beats per minute,7.71 mmol/L,7.2%,2.13 mmol/L and 494μmol/L before MTM services to<130/80 mmHg,55-60 beats per minute,6.22 mmol/L,6.3%,1.55 mmol/L and 348μmol/L after MTM services.CONCLUSIONS The pharmacists providing MTM services to the patients can improve their quality of life and therapeutic efficacy,reduce medication risks,and enhance the level of rational drug use in hospitals and pharmaceutical service capabilities.