摘要
1例87岁男性患者,因“嗜睡、健忘、精神差、四肢乏力2周”入院,入院诊断为:意识障碍待查:脑梗死?高血压病3级(很高危)、高血压性心脏病;冠状动脉粥样硬化性心脏病;2型糖尿病、糖尿病肾病;右侧脑桥陈旧性脑梗塞。入院后发现肌酐244.0μmol·L-1,计算得预估肾小球滤过率19.725 mL·min^-1·1.73 m^-2,临床医生将盐酸二甲双胍缓释片调整为阿卡波糖片。临床药师根据患者的生理病理情况和病情变化,建议改用瑞格列奈片(0.5 mg,tid),意见被采纳,但剂量改为1 mg。第2日监测血糖发现患者低血糖,但无不适,考虑瑞格列奈和氯吡格雷的相互作用引起,予暂时停用瑞格列奈。第3日患者餐后2 h血糖升高,临床药师建议加用瑞格列奈片(0.5 mg,tid),意见被采纳。之后临床药师持续关注患者的血糖监测情况,对患者进行用药教育,患者血糖控制可。
One 87-year-old male patient was admitted to the hospital due to drowsiness,forgetfulness,poor spirit and limb weakness for 2 weeks and diagnosed as consciousness disorder of unknow origin,cerebral infarction?hypertension grade 3(very high risk),hypertensive heart disease,coronary atherosclerotic heart disease,type 2 diabetes mellitus,diabetic nephropathy,and old cerebral infarction of right pontine.After admission,result of blood test showed that the creatinine was 244.0μmol·L-1,based on which estimated glomerular filtration rate(eGFR)was calculated as 19.725 mL·min^-1·1.73 m^-2.Physicians planned to use acarbose tablets to replace metformin hydrochloride sustained-release tablets,But clinical pharmacist suggested giving repaglinide tablets(0.5 mg,tid)instead according to the patient's physiological and pathological status and the change of his conditions.At last,repaglinide(1 mg,tid)was given to the patient.But he developed asymptomatic hypoglycemia on the next day,which was considered as the result of drug interaction between the repaglinide and clopidogrel.So repaglinide was temporarily stopped.On the third day,the 2-hour postprandial blood glucose of the patient was increased and repaglinide(0.5 mg,tid)was given to him suggested by clinical pharmacist.Thereafter,clinical pharmacist continued monitoring the level of his blood glucose and provided medication education to him.The patient's blood glucose was well controlled.
作者
吕达娜
LV Da-na(Department of Pharmacy,910th Hospital of PLA,Quanzhou 362000,China)
出处
《中国药物应用与监测》
CAS
2020年第4期242-245,共4页
Chinese Journal of Drug Application and Monitoring
基金
泉州市科技计划项目(2018N136S)。
关键词
缺血性脑卒中
2型糖尿病
慢性肾功能不全
药学监护
Cerebral ischemic stroke
Type 2 diabetes mellitus
Chronic renal insufficiency
Pharmaceutical care
