1例免疫抑制剂致肾功能不全患者继发卡氏肺孢子菌肺炎的药学监护
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篇名: 1例免疫抑制剂致肾功能不全患者继发卡氏肺孢子菌肺炎的药学监护
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摘要: 目的:探讨临床药师对免疫抑制剂致肾功能不全患者继发卡氏肺孢子菌肺炎药学监护的体会。方法:中国中医科学院广安门医院于2017年5月收治的1例主因双下肢浮肿伴发热咳嗽的患者,其收治前8年内大剂量使用了糖皮质激素、环磷酰胺、吗替麦考酚酯等免疫抑制药物,入院后确诊为抗中性粒细胞胞浆抗体相关性血管炎、Ⅲ型新月体性肾炎、膜性肾病,且卡氏肺孢子菌检测呈阳性。临床药师从抗菌、抗卡氏肺孢子菌、降压、糖皮质激素使用等方面为其提供药学监护和用药教育。结果:针对患者入院前用药情况和入院后医师开具的用药方案,临床药师建议停用抗感染药物注射用亚胺培南西司他丁钠和克林霉素磷酸酯片,更换为肾功能不全患者无须减量的莫西沙星、卡泊芬净等药物,加用福辛普利降压治疗,同时保护残存肾单位,对患者服用糖皮质激素进行用药教育,告知其潜在的不良反应及应对策略。医师和患者均认可并采纳临床药师的意见,患者感染症状得到控制,血压降至正常范围,下肢水肿好转,肾功能逐渐恢复后出院。结论:临床药师通过药学监护,可优化患者的用药方案,有助于提高疗效、改善预后,促进临床合理用药。
ABSTRACT: OBJECTIVE: To investigate the experience of clinical pharmacists in pharmaceutical care for immunosuppressive agent-induced renal insufficiency patients with secondary Pneumocystis carinii pneumonia. METHODS: A patient with edema of both lower limbs fever and cough was admitted to Guang’anmen Hospital of Chinese Academy of TCM in May 2017. The patient was given large dose of glucocorticoids, cyclophosphamide, mycophenolate mofetil and other immunosuppressive agent during the past 8 years. After admission, the patient was diagnosed as anti-neutrophil cytoplasmic antibody-associated vasculitis, type Ⅲ crescent glomerulonephritis, membranous nephropathy, and P. carinii gene test was positive. Clinical pharmacists provided pharmaceutical care and medication education from the aspects of antibacterial, anti-P. carinii, antihypertension, and glucocorticoid use. RESULTS: According to the patient’s medication befor admission and medication plan prescribed by the physician after admission, clinical pharmacists recommend replacing anti-infective drugs as Imipenem and cliastatin sodium for injeetion and clindamycin phosphate tablet with moxifloxacin and captopril which were not required to reduce dose in renal insufficiency patient, adding fosinopril to the treatment of hypertension, protecting the residual nephron, providing medication education for the patient about the use of glucocorticoids, and informing the patient of potential adverse reactions and countermeasures. Doctors and patients agreed and accepted the opinions of clinical pharmacists; the patient was discharged from the hospital after the patient’s infection symptoms were controlled, blood pressure dropped to normal range, lower limb edema improved, and renal function gradually recovered. CONCLUSIONS: Through pharmaceutical care, clinical pharmacists can optimize the medication program of patients, help to improve the curative effect, improve the prognosis, and promote clinical rational drug use.
期刊: 2018年第29卷第21期
作者: 李思聪,杨金亮,王青青
AUTHORS: LI Sicong,YANG Jinliang,WANG Qingqing
关键字: 免疫抑制剂;肾功能不全;卡氏肺孢子菌肺炎;药学监护
KEYWORDS: Immunosuppressive agent; Renal insufficiency; Pneumocystis carinii pneumonia; Pharmaceutical care
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