【作者】 周美辰； 郑萍；

【Author】 ZHOU Mei-chen;ZHENG Ping;Guangzhou Chest Hospital;Nanfang Hospital of Southern Medical University;

【机构】 广州市胸科医院药剂科； 南方医科大学南方医院药学部；

【摘要】 目的:通过对1例非瓣膜病房颤合并肾功能不全患者服用华法林后INR异常升高及波动的分析和干预,探讨临床药师在特殊人群应用华法林抗凝治疗中的个体化药学监护。方法:评估药物相互作用、华法林用药基因检测和疾病状态对华法林抗凝作用的影响。结果:日夜百服咛中的对乙酰氨基酚、苯溴马隆、艾司奥美拉唑、螺内酯、NSAIDs及其他抗栓药物(肝素、依诺肝素、氯吡格雷)都可以影响华法林的抗凝效果,华法林VKORC1 1639G>A基因多态性、肝肾功不全等疾病状态亦可解释该患者对华法林所需维持剂量较低的现象。临床药师对患者的治疗方案进行了个体化药学监护,并对患者进行了华法林用药教育。结论:相互作用、华法林基因多态性和疾病状态多因素综合影响华法林的药动学和药效学。临床药师参与华法林抗凝治疗的个体化药学服务,有助于加强应用华法林的房颤合并肾功能不全患者的抗凝管理。更多还原

【Abstract】 Objective: To explore the role of clinical pharmacists in the application of individualized pharmaceutical care in warfarin anticoagulant therapy in special populations by analysis and intervention of abnormal INR elevation and fluctuation after taking warfarin in 1 patient with non-valvular atrial fbrillation complicated with renal insufciency. Methods: The effects of drug interactions, warfarin gene detection, and disease status on warfarin anticoagulation were assessed. Results: Paracetamol, benzbromarone, esomeprazole, spirolactone, NSAIDs and other antithrombotic medicines could affect warfarin anticoagulation effect. The phenomenon of the requirement of a lower maintenance dose for warfarin in this patient could also be explained by VKORC1 1639G>A polymorphism and conditions such as renal insufciency and so on. The clinical pharmacist conducted individualized pharmacological monitoring to the patient’s treatment plan and educated the patient on warfarin medication. Conclusion: The pharmacokinetics and pharmacodynamics of warfarin could be comprehensively affected by multifactors including drug interaction, warfarin pharmacogenetics and disease status. The participation of clinical pharmacists in the individualized pharmacy services of warfarin anticoagulant therapy can help to improve anticoagulation management of warfarin in patients with atrial fbrillation complicated with renal insufciency..更多还原