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1 例肺血栓栓塞症伴多种合并症乳腺癌患者的抗凝治疗分析与

药学监护
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2 #
霍 萌 1， 2＊ ，程齐俭 ，林佳媛 （1.温州医科大学附属第一医院药学部，浙江 温州 325000；2.上海交通大学医学院
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附属瑞金医院药学部，上海 201801；3. 上海交通大学医学院附属瑞金医院呼吸与危重症医学科，上海
201801）

中图分类号 R969.3 文献标志码 A 文章编号 1001-0408（2025）02-0219-06
DOI 10.6039/j.issn.1001-0408.2025.02.15
摘 要 目的 为肺血栓栓塞症（PTE）伴多种合并症乳腺癌患者的抗凝治疗和药学监护提供参考。方法 临床药师参与1例PTE
合并继发于系统性红斑狼疮的可疑抗磷脂综合征伴血小板重度减少的乳腺癌患者的诊疗过程，并提供制订个体化抗凝方案、监测
患者出血情况等药学监护。针对患者出现的PTE，临床药师建议停用所有乳腺癌治疗药物；针对初始抗凝方案，临床药师在明确
血小板重度减少并非抗凝治疗的绝对禁忌证后，建议予磺达肝癸钠注射液抗凝治疗；针对长期抗凝方案和疗程，临床药师建议优
选华法林，推荐疗程至少3～6个月，并根据12周后的抗磷脂抗体谱复查结果结合肿瘤治疗方案决定是否进行无限期抗凝治疗。
结果 医师采纳临床药师建议。经治疗后，患者血丝痰及气促消失，血小板恢复正常，准予带药出院。结论 临床药师以“抗凝-出
血”为切入点，通过分析乳腺癌治疗相关药物与PTE的因果关系、充分评估患者的出血和血栓复发风险、监测患者出血症状和体征
及凝血指标等药学服务，为患者制定了个体化用药方案，保障了患者用药的安全有效。
关键词 肺血栓栓塞症；血小板重度减少；抗磷脂综合征；抗凝治疗；临床药师；药学监护

Anticoagulation therapy analysis and pharmaceutical care for a breast cancer patient with pulmonary
thromboembolism accompanied by multiple comorbidities
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1， 2
HUO Meng ，CHENG Qijian ，LIN Jiayuan（1. Dept. of Pharmacy， the First Affiliated Hospital of Wenzhou
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Medical University， Zhejiang Wenzhou 325000， China；2. Dept. of Pharmacy， Ruijin Hospital， Shanghai Jiao
Tong University School of Medicine， Shanghai 201801， China；3. Dept. of Pulmonary & Critical Care
Medicine， Ruijin Hospital， Shanghai Jiao Tong University School of Medicine， Shanghai 201801， China）

ABSTRACT OBJECTIVE To provide a reference for anticoagulant therapy and pharmaceutical care of the breast cancer patient
with pulmonary thromboembolism （PTE） accompanied by multiple comorbidities. METHODS Clinical pharmacists participated in
the diagnosis and treatment of a breast cancer patient with PTE accompanied by severe thrombocytopenia and suspected
antiphospholipid syndrome secondary to systemic lupus erythematosus， and provided personalized pharmaceutical care as
developing individualized anticoagulation plans and monitoring patient bleeding. For the occurrence of PTE， the clinical pharmacist
recommended stopping all breast cancer drugs. The clinical pharmacists also cleared that severe thrombocytopenia was not the
absolute contraindication for anticoagulant treatment and suggested fondaparinux sodium as the initial anticoagulation regimen.
Further， warfarin was recommended as the long-term anticoagulation regimen with a recommended treatment course of at least 3-6
months by the clinical pharmacists. Whether to continue indefinite anticoagulation therapy was based on the results of the
antiphospholipid antibodies after 12 weeks combined with the tumor treatment regimen. RESULTS The physicians adopted the
advice of the clinical pharmacists. After treatment， the patient’s blood phlegm and anhelation disappeared and the platelets returned
to normal. The patient was allowed to be discharged with medication. CONCLUSIONS Taking the “anticoagulation-bleeding” as
the starting point， the clinical pharmacists develop individualized medication plans for patients so as to ensure the safety and
effectiveness of medication in the patient by providing pharmaceutical care， such as analyzing the causal relationship between breast
cancer treatment-related drugs and PTE， assessing the risk of bleeding and thrombus recurrence， and monitoring patients’ bleeding
symptoms and signs and coagulation indicators.
KEYWORDS pulmonary thromboembolism； severe thrombocytopenia； antiphospholipid syndrome； anticoagulation； clinical
pharmacist； pharmaceutical care
Δ 基金项目 上海申康医院发展中心市级医院诊疗技术推广及优
化管理项目（No.SHDC12022108）
＊第一作者 药师。研究方向：临床药学。E-mail：huomeng8503@
肺栓塞是以各种栓子阻塞肺动脉或其分支为发病
163.com
原因的一组疾病或临床综合征的总称，以肺血栓栓塞症
# 通信作者 主管药师，硕士。研究方向：呼吸临床药学。E-mail：
linjiayuan1987@126.com （pulmonary thromboembolism，PTE）最为常见。PTE 与

中国药房 2025年第36卷第2期 China Pharmacy 2025 Vol. 36 No. 2 · 219 ·