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1例复杂性静脉血栓栓塞症合并急性肾功能不全患者的抗凝药物治疗管理
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| 篇名： | 1例复杂性静脉血栓栓塞症合并急性肾功能不全患者的抗凝药物治疗管理 |
| TITLE： | Management of anticoagulant therapy in a patient with complex venous thromboembolism complicated with acute renal insufficiency |
| 摘要： | 目的 为复杂性静脉血栓栓塞症（VTE）合并急性肾功能不全患者的安全用药提供参考。方法临床药师参与1例复杂性VTE合并急性肾功能不全患者的抗凝药物治疗管理，通过患者病史、实验室检查结果等，评估其属于血栓形成高危和出血高危患者；结合该患者血栓复杂程度和肾功能不全，建议其在血栓急性期（发病5～21d）选用依诺肝素钠，随后桥接华法林口服抗凝治疗；针对该患者抗凝不达标（国际标准化比值目标范围为2～3），建议增加华法林剂量并行华法林药物基因检测，根据基因分型调整华法林剂量；同时制定抗凝监护计划，确保抗凝治疗的安全性。结果医师采纳了临床药师的建议。患者住院抗凝治疗期间未发生出血或血栓栓塞加重等不良事件，抗凝达标，准予带药出院。结论临床药师通过参与复杂性VTE合并急性肾功能不全患者的抗凝药物治疗管理，协助医师制定个体化抗凝方案，促进了患者抗凝治疗达标，确保了其用药安全、有效。 |
| ABSTRACT： | OBJECTIVE To provide a reference for the safe use of drugs in patients with complex venous thromboembolism （VTE） and acute renal insufficiency. METHODS Clinical pharmacists participated in the management of anticoagulant therapy for a patient with complex VTE complicated with acute renal insufficiency， and evaluated the patient as high-risk thrombosis and bleeding based on their medical history， laboratory test results， etc.； combined with the complexity of thrombosis and renal insufficiency， clinical pharmacists suggested that enoxaparin sodium should be used in the acute stage of thrombosis （5 to 21 days after onset）， and then warfarin should be adopted for oral anticoagulation treatment. Because the patient’s anticoagulation was not up to the standard （the target range of the international normalized ratio was 2-3）， clinical pharmacists suggested increasing the warfarin dose， detecting the warfarin metabolism genotype， and adjusting the warfarin dose according to the genotype； at the same time， clinical pharmacists developed an anticoagulation monitoring plan to ensure the safety of anticoagulation treatment. RESULTS Doctors had adopted all the recommendations of clinical pharmacists. The patient did not experience adverse events such as bleeding or worsening of thromboembolism during anticoagulation in the hospital. When the anticoagulation met the standards， the patient was allowed to be discharged with medication. CONCLUSIONS By participating in the anticoagulation treatment management of patients with complex VTE and acute renal insufficiency， clinical pharmacists have assisted doctors in formulating personalized anticoagulation plans to promote the compliance with the anticoagulation treatment standard and ensure the safety and effectiveness of medication for patients. |
| 期刊： | 2023年第34卷第18期 |
| 作者： | 黄永佳；江德全；丁玲；刘洁；贺小艳；李小亚；黄婉婷；李金豆 |
| AUTHORS： | HUANG Yongjia，JIANG Dequan，DING Ling，LIU Jie，HE Xiaoyan，LI Xiaoya，HUANG Wanting，LI Jindou |
| 关键字： | 静脉血栓栓塞症；肾功能不全；抗凝治疗；基因分型；药学监护 |
| KEYWORDS： | venous thromboembolism； renal insufficiency； anticoagulant therapy； genotype； pharmaceutical monitoring |
| 阅读数： | 57 次 |
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