Page 116 - 2020年19期

·药师与药学服务·

临床药师开展慢性肾脏病患者的药物重整实践 Δ

2 #
司方莹 ，薛 莹 ，岳晓红 （1.郑州大学第一附属医院药剂科，郑州 450052；2.郑州大学第一附属医院血液净
1＊
1
化中心，郑州 450052）
中图分类号 R969.3 文献标志码 A 文章编号 1001-0408（2020）19-2410-05
DOI 10.6039/j.issn.1001-0408.2020.19.19

摘 要 目的：为临床药师开展慢性肾脏病（CKD）药学服务提供参考。方法：以2019年1月1日－9月30日收入或转入我院肾内
科的诊断为CKD的住院患者为研究对象，由临床药师主导，通过药学问诊、查看病历、分析总结药物相关问题并进行药物重整，向
医师提出药物重整建议，为患者提供重整后用药清单并进行用药教育。结果与结论：共获得130例CKD患者的用药情况，临床药
师对其中85例进行了药物重整，重整率为65.38％，85例患者涉及193条医嘱，其中占医嘱比例居前3位的药物相关问题分别是用
法用量不适当（41.96％）、药物相互作用（18.13％）、药物选用不适当（14.51％）；居前3位的重整药物类别分别为心血管系统类药物
（26.94％）、纠正矿物质及骨代谢异常的药物（22.28％）、抗菌药物（16.02％）。临床药师的重整方案以改药（71例，36.78％）、停药
（42例，21.76％）和加药（35例，18.13％）为主，其次为更改服药时间、调整剂量，多数（88.08％）被医师和患者接受。临床药师通过
药物重整，可减少药物相关问题的发生。鉴于CKD患者多数年龄较大、并发症多、服药种类多，且部分药物因患者肾功能改变需
进行剂量调整，故临床药师开展CKD患者的药物重整时应重点关注用法用量问题，特别是心血管系统类药物、纠正矿物质及骨代
谢异常的药物，协助医师最大程度地保证患者用药安全。
关键词 临床药师；慢性肾脏病；药物重整

Practice of Clinical Pharmacist Participating in Medication Reconciliation for Patients with Chronic
Kidney Disease
1
2
SI Fangying ，XUE Ying ，YUE Xiaohong（1. Dept. of Pharmacy，the First Affiliated Hospital of Zhengzhou
1
University，Zhengzhou 450052，China；2. Blood Purification Center，the First Affiliated Hospital of Zhengzhou
University，Zhengzhou 450052，China）
ABSTRACT OBJECTIVE：To provide reference for developing pharmaceutical care of chronic kidney disease（CKD）by clinical
pharmacists. METHODS：During 1st，Jan. to 30th，Sept. in 2019，inpatients diagnosed as CKD admitted or transferred to
nephrology department of our hospital were selected. Medication reconciliation was conducted by clinical pharmacists after
pharmaceutical consultation，reviewing medical records，analyzing and summarizing drug-related problem （DRP）. Medication
reconciliation recommendations were proposed to physician. Subsequently，drug list and medical education were provided to
patients by clinical pharmacists. RESULTS & CONCLUSIONS：The medication information of 130 patients was collected，and 85
of them were provided with medication reconciliation by clinical pharmacist，with a reconciliation rate of 65.38％. There were 193
medical orders involved 85 patients. Among all the DRP，the top three of proportion in medical orders were improper drug usage
and dosage（41.96％），drug interactions（18.13％）and improper drug selection（14.51％）. Among drugs related to medication
reconciliation，top three types were cardiovascular system drugs（26.94％），drug correcting mineral and bone metabolism disorder
（22.28％）and antibacterial drugs（16.02％）. The main plans of medication reconciliation were drug change（71 cases，36.78％），
drug withdrawal（42 cases，21.76％），drug supplement（35 cases，18.13％），followed by change of medication time and dosage
adjustment. The majority （88.08％） of the recommendations were accepted by physician and patients. Clinical pharmacists can
reduce the occurrence of DRP by medication reconciliation. The majority of patients with CKD were elderly and complicated with
multiple diseases and took various drugs，and part of drugs required dose adjustment due to the change of kidney function，therefor
clinical pharmacists implementing medication reconciliation to CKD，should pay attention to drug usage and dosage，especially
cardiovascular system drug，drug correcting mineral and bone
Δ 基 金 项 目 ：国 家 重 点 研 发 计 划 精 准 医 学 研 究 重 点 专 项
（No.2017YFC0909900） disorder，and assist physicians to ensure safety of drug use in
＊主管药师，硕士。研究方向：临床药学。电话：0371-66862639。 patients.
E-mail：fangying900818@163.com KEYWORDS Clinical pharmacist；Chronic kidney disease；
# 通信作者：副主任护师，硕士。研究方向：护理管理、护理教 Medication reconciliation
育。电话：0371-66913301。E-mail：Yuexiaohong2009@126.com

·2410 · China Pharmacy 2020 Vol. 31 No. 19 中国药房 2020年第31卷第19期