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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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          黄永佳 ,江德全 ,丁 玲 ,刘 洁 ,贺小艳 ,李小亚 ,黄婉婷 ,李金豆 (1.重庆市江津区中心医院药学部,
                           2
          重庆 402260;2.重庆市江津区中心医院胃肠外科,重庆 402260)
          中图分类号  R969.3;R972      文献标志码  A      文章编号  1001-0408(2023)18-2274-04
          DOI  10.6039/j.issn.1001-0408.2023.18.18
          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5~21 d)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。
          关键词  静脉血栓栓塞症;肾功能不全;抗凝治疗;基因分型;药学监护

          Management  of  anticoagulant  therapy  in  a  patient  with  complex  venous  thromboembolism  complicated
          with acute renal insufficiency
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          HUANG Yongjia ,JIANG Dequan ,DING Ling ,LIU Jie ,HE Xiaoyan ,LI Xiaoya ,HUANG Wanting ,
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          LI Jindou(1.  Dept.  of  Pharmacy,  Central  Hospital  of  Chongqing  Jiangjin  District,  Chongqing  402260,  China;
                   2
          2. Dept. of Gastrointestinal Surgery, Central Hospital of Chongqing Jiangjin District, Chongqing 402260, China)
          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.
          KEYWORDS     venous thromboembolism; renal insufficiency; anticoagulant therapy; genotype; pharmaceutical monitoring


              静脉血栓栓塞症(venous thromboembolism,VTE)             月,国家卫生健康委医政医管局出台了医疗质量安全十
          是全球三大致死性心血管疾病之一,因起病隐匿、发生                            大改进目标,其中第5个目标就是提高VTE的规范预防
          快速、致死率高而被学界称为“隐形杀手”。2021 年 2                        率,并希望通过医疗机构内多学科、多部门协作构建
                                                                                                        [1]
                                                              VTE防治体系,降低患者VTE不良事件的发生率 。临
              Δ 基金项目 重庆市临床重点专科建设项目(No.渝卫办发〔2022〕
                                                              床药师是VTE防治体系中不可或缺的一员,可协助医师
          7号);重庆市临床药学重点专科建设项目(No.渝卫办发〔2023〕2号)                选择适宜的抗凝药物及剂量、疗程,并充分权衡患者的
             * 第一作者 药 师 ,硕 士 。 研 究 方 向 :临 床 药 学 。 电 话 :023-
                                                              血栓-出血风险,从而提高抗凝治疗的安全性和有效
          47225178。E-mail:1074717950@qq.com
                                                                [2]
              # 通信作者 主治医师,硕士。研究方向:普通外科学。电话:023-               性 。本文介绍了1例复杂性VTE合并急性肾功能不全
          47548034。E-mail:847323002@qq.com                    患者的抗凝药物治疗管理方案,初步探讨了临床药师如

          · 2274 ·    China Pharmacy  2023 Vol. 34  No. 18                            中国药房  2023年第34卷第18期
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