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·药学服务·
乳腺癌伴慢性肾脏病患者的个体化治疗与药学监护
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俞 璐 ，吴旭栋 ，张 明（1.宁波市鄞州区第二医院临床药学部，浙江 宁波 315100；2.宁波市鄞州区第二
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医院医共体钟公庙分院内科，浙江 宁波 315100）
中图分类号 R969.3 文献标志码 A 文章编号 1001-0408（2025）07-0853-05
DOI 10.6039/j.issn.1001-0408.2025.07.15
摘 要 目的 为乳腺癌伴慢性肾脏病（CKD）患者的个体化治疗和临床药学实践提供参考。方法 临床药师参与 1 例乳腺癌伴
CKD患者的抗肿瘤治疗过程并提供药学监护。临床药师查阅指南与文献，协助医生制定术前初始新辅助化疗方案（多西他赛+曲
妥珠单抗+帕妥珠单抗），并就方案所含药物可能引发的呕吐、骨髓抑制、肾功能损害、心脏毒性等不良反应提出监护建议；针对患
者治疗后出现的急性肾损伤，临床药师通过关联性评价协助医生分析不良反应产生原因，并结合患者意愿，将多西他赛替换为紫
杉醇（无需根据肾功能调整剂量）；临床药师协助医生确定术后靶向治疗方案（曲妥珠单抗+帕妥珠单抗），考虑到患者为雌激素受
体阳性，建议其在放疗结束后规律服用阿那曲唑并定期检测骨密度。结果 医生接受临床药师建议。患者顺利完成术前新辅助化
疗和术后靶向治疗，带药（阿那曲唑）出院；治疗期间，未出现骨髓抑制、心脏毒性等不良反应，后续也未发生骨质疏松。结论 临床
药师根据患者肾功能分析调整术前/术后抗肿瘤治疗方案，及时评估抗肿瘤药物与急性肾损伤的关联性，积极开展全流程药学监
护，保障了乳腺癌伴CKD患者的用药安全。
关键词 乳腺癌；慢性肾脏病；术前新辅助化疗；术后靶向治疗；临床药师；药学监护
Individualized treatment and pharmaceutical care for breast cancer complicated with chronic kidney
disease
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YU Lu ，WU Xudong ，ZHANG Ming（1. Dept. of Clinical Pharmacy， Ningbo Yinzhou District No.2 Hospital，
Zhejiang Ningbo 315100， China；2. Dept. of Internal Medicine， Zhonggongmiao Community Hospital of Ningbo
Yinzhou District No.2 Hospital Medical Community， Zhejiang Ningbo 315100， China）
ABSTRACT OBJECTIVE To provide a reference for individualized treatment and pharmaceutical care for patients with breast
cancer complicated with chronic kidney disease （CKD）. METHODS Clinical pharmacists participated in the anti-tumor treatment
and pharmaceutical care for a breast cancer patient with CKD. Clinical pharmacists reviewed guidelines and literature to assist the
clinical physician in formulating the initial neoadjuvant treatment plan （docetaxel+trastuzumab+paltuzumab） and provided
monitoring recommendations for potential adverse drug reactions， such as vomiting， myelosuppression， renal impairment，
cardiotoxicity. In response to the patient’s acute kidney injury after treatment， clinical pharmacists assisted the physician in
analyzing the cause of the adverse reaction through causality assessment. Taking into account the patient’s preferences， docetaxel
was substituted with paclitaxel （which did not require dose adjustment based on renal function）. The clinical pharmacists collaborated
with the physician to establish a postoperative targeted therapy regimen （trastuzumab+pertuzumab）. Taking into account the
patient’s positive estrogen receptor status， the clinical pharmacists recommended to initiate regular anastrozole administration after
the completion of radiotherapy and undergo periodic bone density assessments. RESULTS The clinical physician accepted the
suggestions from the clinical pharmacists. The patient successfully completed preoperative neoadjuvant chemotherapy and
postoperative targeted therapy， and was discharged with medication （anastrozole）. During the treatment process， the patient did not
experience adverse reactions such as myelosuppression， cardiotoxicity， or the occurrence of osteoporosis. CONCLUSIONS Clinical
pharmacists analyzed and adjusted the preoperative and postoperative antitumor treatment plans based on the patient’s renal
function. They promptly assessed the correlation between
Δ 基金项目 浙江省医药卫生科技计划项目（No.2021KY1068）
＊第一作者 主管药师，硕士。研究方向：临床药学（肾内科方向）。 antitumor drugs and acute kidney injury， and actively
E-mail：yulusyph@sina.com implemented comprehensive pharmaceutical care to ensure
# 通信作者 主治医师。研究方向：慢性疾病治疗与管理。E- medication safety for breast cancer patients with CKD.
mail：2377651334@qq.com
中国药房 2025年第36卷第7期 China Pharmacy 2025 Vol. 36 No. 7 · 853 ·
