摘要
目的:探讨药师如何通过药物治疗管理(Medication therapy management,MTM)结合药物基因检测为患者提供个体化药学服务,以促进临床合理用药。方法:以1例服用华法林钠片导致急性上消化道出血的老年共病患者(该患者有2型糖尿病、高血压史,入院2个月前行冠状动脉旁路移植术,半个月前患泌尿系统感染)为例,回顾性分析患者住院前后药物治疗过程,结合CYP2C9*3、VKORC1-1639基因分型检测,评估华法林钠片个体化给药剂量,针对急性上消化道出血及患者所有用药进行MTM,制订个体化药物治疗方案。结果:华法林CYP2C9*3、VKORC1-1639的基因分型测定提示患者为超慢代谢型,推荐华法林给药剂量应为0.86~1.86 mg/d,结合急性上消化道出血情况进行MTM分析,患者使用华法林钠片3.0 mg/d、用药依从性差、疾病状态及共病多药联合可能是导致急性上消化道出血的主要原因,患者停用华法林及对症治疗后临床消化道出血好转,抗凝药物更换为利伐沙班片10 mg/d。通过对患者所有用药进行MTM,药物重整结果显示,停用盐酸地尔硫片、阿莫西林克拉维酸钾分散片、复合维生素片,将降糖药物格列美脲片更换格列喹酮片,冠状动脉旁路移植术后用药酒石酸美托洛尔片更换为比索洛尔片,质子泵抑制剂艾司奥美拉唑肠溶片更换为泮托拉唑钠肠溶胶囊。结论:MTM结合药物基因检测的药学服务模式可指导临床安全合理用药,实现个体化药学服务,提高患者依从性,预防药品不良反应相关问题。
OBJECTIVE:To investigate how pharmacists provide through individualized pharmaceutical care for patients medication therapy management(MTM) combined with medicine gene detection,and to promote rational drug use in clinic. METHODS:A case of elderly comorbidity with acute upper gastrointestinal hemorrhage caused by Warfarin sodium tablets was taken as an example. The patient had a history of type 2 diabetes mellitus and hypertension. Coronary artery bypass grafting was performed two months before admission,and urinary tract infection occurred half a month ago. Medication therapy course was analyzed retrospectively before and after hospitalization;based on gene typing detection of CYP2C9*3 and VKORC1-1639,the individualized dose of Warfarin sodium tablets was evaluated. MTM was perfomed for acute upper gastrointestinal hemorrhage and all medication of patient to formulate individualized medication scheme. RESULTS:The genotyping of warfarin CYP2C9*3 and VKORC1-1639 indicated that the patients were of super slow metabolic type. The recommended dosage of warfarin should be 0.86-1.86 mg/d. Based on MTM analysis of acute upper gastrointestinal hemorrhage,the main causes of acute upper gastrointestinal hemorrhage were Warfarin sodium tablets 3.0 mg/d,poor drug compliance,disease status and co-morbidity and multi-drug combination. Clinical gastrointestinal hemorrhage of the patients were improved after drug withdrawal,anticoagulant drugs was changed into Rivaroxaban tablet,10 mg/d. Through MTM for all drug use in the patient,results of medication reorganization showed that Diltiazem hydrochloride tablet, Amoxicillin/ clavulanate potassium dispersible tablet, Compound vitamin tablet were stopped;hypoglycemic drug Glimepiride tablet was changed into Gliquidone tablet;Metoprolol tartrate tablet was changed into Bisoprolol tablet after coronary artery bypass graft;proton pump inhibitor Esomeprazole enteric-coated tablet was changed into Pantoprazole sodium enteric-coated capsule. CONCLUSIONS:The pharmaceutical care mode of MTM
作者
王兰
毛乾泰
张小宁
冀召帅
艾超
WANG Lan;MAO Qiantai;ZHANG Xiaoning;JI Zhaoshuai;AI Chao(Beijing Tsinghua Changgung Hospital,School of Clinical Medicine,Tsinghua University,Beijing 102218,China;School of Medicine,Tsinghua University,Beijing 100084,China)
出处
《中国药房》
CAS
北大核心
2019年第17期2388-2393,共6页
China Pharmacy
基金
国家科技重大专项（No.2018ZX09733001-006-007）
关键词
华法林
药物治疗管理
药物基因检测
个体化药学服务
Warfarin
Medication therapy management
Medicine gene detection
Individualized pharmaceutical care
