临床药师参与1例下肢静脉血栓伴肺动脉血栓栓塞症患者华法林个体化抗凝治疗方案的病例分析-中国药房

临床药师参与1例下肢静脉血栓伴肺动脉血栓栓塞症患者华法林个体化抗凝治疗方案的病例分析

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篇名：	临床药师参与1例下肢静脉血栓伴肺动脉血栓栓塞症患者华法林个体化抗凝治疗方案的病例分析
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摘要：	目的：探讨临床药师在下肢静脉血栓伴肺动脉血栓栓塞症患者华法林个体化抗凝治疗中的作用。方法：临床药师参与1例下肢静脉血栓伴肺动脉血栓栓塞症患者的华法林个体化抗凝治疗过程，建议检测患者基因类型，并根据其基因检测结果[细胞色素P450（CYP）2C911和维生素K环氧化物还原酶复合体亚单位1（VKORC1）1399AA]及美国FDA推荐剂量，结合其生活习惯、身高和体质量等确定华法林初始剂量（3.125 mg，每日1次），再根据华法林药物基因组学联合会建立的华法林维持剂量预测公式计算华法林的维持剂量（2.5 mg和3.125 mg，每日1次，隔日交替剂量服用）；建议给予对华法林影响较小的氟氯西林钠注射液剂量频次治疗，并行国际标准化比值、凝血酶原时间等相关参数及出血事件监测等药学监护。结果：医师采纳临床药师的建议，2.5 mg和3.125 mg，每日1次，隔日交替剂量服用，建议给予对华法林影响较小的氟氯西林钠注射液剂量频次治疗。患者恢复良好，准予带药出院。结论：临床药师基于药物基因组学参与患者华法林个体化抗凝方案的制定，可促进患者国际标准化比值的提高，降低其术后早期血栓栓塞及出血风险，进一步确保了患者用药安全、有效。
ABSTRACT：	OBJECTIVE： To investigate the role of clinical pharmacists in the individual anticoagulation of warfarin for the patients with lower extremity venous thrombosis （LEVT） and pulmonary arterial thromboembolism （PATE）. METHODS： Clinical pharmacists participated in individual anticoagulation of warfarin for the patients with LEVT and PATE. It was suggested to detect the gene type of the patient. According to the results of gene test [cytochrome P450 （CYP）2C911 and vitamin K epoxide reductase complex subunit Ⅰ] and the dose recommended by FDA based on the patient’s gene， the initial dose of warfarin （3.125 mg，once a day） was determined according to the patient’s living habits， height and body mass. Then the maintenance dose of warfarin （the maintenance dose of warfarin was 2.5 mg and 3.125 mg， once a day， alternately taken every other day） was calculated according to the warfarin maintenance dose prediction formula established by Warfarin Pharmaeogenetics Consortium. Pharmaceutical monitoring was conducted， such as INR， prothrombin time and bleeding event monitering. RESULTS： Physicians adopted the suggestion of clinical pharmacists. The maintenance dose of warfarin was 2.5 mg and 3.125 mg， once a day， alternately taken every other day. It was suggested to give Flucloxacillin sodium injection which had less influence on warfarin. The patient recovered well and was discharged. CONCLUSIONS： Based on pharmacogenomics， clinical pharmacists participate in the formulation of individualized anticoagulant regimens for patients， which promote TNR ralue of patients， reduce the risk of early postoperative thromboembolism， and further ensure the safety of drug use in patients.
期刊：	2019年第30卷第6期
作者：	邓明影，张蕾，冯晓俊，史天陆，姜玲
AUTHORS：	DENG Mingying，ZHANG Lei，FENG Xiaojun，SHI Tianlu，JIANG Ling
关键字：	华法林；药物基因组学；个体化抗凝；临床药师；下肢静脉血栓；肺动脉血栓栓塞症
KEYWORDS：	Warfarin； Pharmacogenomics； Individualized anticoagulation； Clinical pharmacist； Lower extremities venous thrombosis； Pulmonary arterial thromboembolism
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