Page 89 - 2019年9月第30卷第17期

·临床药学·

药物治疗管理结合药物基因检测在 1 例服用华法林致急性上消

化道出血的老年患者个体化药学服务中的应用 Δ

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1
1 #
1
1＊
王 兰 ，毛乾泰 ，张小宁 ，冀召帅 ，艾 超 （1.清华大学附属北京清华长庚医院/清华大学临床医学院，北京
102218；2.清华大学医学院，北京 100084）
中图分类号 R969.3 文献标志码 A 文章编号 1001-0408（2019）17-2388-06
DOI 10.6039/j.issn.1001-0408.2019.17.17

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。
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

Application of Medication Therapy Management Combined with Medicine Gene Detection in
Individualized Pharmaceutical Care of An Elderly Patient with Warfarin-induced Acute Upper
Gastrointestinal Hemorrhage
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WANG Lan ，MAO Qiantai ，ZHANG Xiaoning ，JI Zhaoshuai ，AI Chao （1.Beijing Tsinghua Changgung
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2
Hospital，School of Clinical Medicine，Tsinghua University，Beijing 102218，China；2.School of Medicine，
Tsinghua University，Beijing 100084，China）
ABSTRACT 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/
Δ 基金项目：国家科技重大专项（No.2018ZX09733001-006-007）
clavulanate potassium dispersible tablet， Compound vitamin
＊主管药师，硕士。研究方向：医院药学、个体化药物治疗。电
tablet were stopped； hypoglycemic drug Glimepiride tablet
话：010-56119564。E-mail：wla00316@btch.edu.cn
# 通信作者：主管药师，硕士。研究方向：医院药事管理、精准药 was changed into Gliquidone tablet；Metoprolol tartrate tablet
学、智能药房管理。电话：010-56118630。E-mail：aca00183@btch. was changed into Bisoprolol tablet after coronary artery bypass
edu.cn graft； proton pump inhibitor Esomeprazole enteric-coated

·2388 · China Pharmacy 2019 Vol. 30 No. 17 中国药房 2019年第30卷第17期