| 张小丹,孙言才.临床药师参与 1例大剂量甲氨蝶呤排泄延迟的案例分析[J].安徽医药,2021,25(3):629-632. |
| 临床药师参与 1例大剂量甲氨蝶呤排泄延迟的案例分析 |
| Clinical pharmacists participating in a case of delayed excretion of high-dose methotrexate: case analysis |
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| DOI：10.3969/j.issn.1009-6469.2021.03.050 |
| 中文关键词: 药学服务 药物相关性副作用和不良反应 临床药师 甲氨蝶呤 延迟排泄 |
| 英文关键词: Pharmaceutical services Drug-related side effects and adverse reactions Clinical pharmacists Methotrexate Delayed excretion |
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| 中文摘要: |
| 目的通过临床药师参与救治大剂量甲氨蝶呤( HD-MTX)排泄延迟病人，促进临床 HD-MTX的安全、合理使用。方法安徽省肿瘤医院临床药师对 2018年 10月收治的 1例 HD-MTX排泄延迟病人实施全程化药学监护，积极分析甲氨蝶呤排泄延迟发生原因及血药浓度波动原因，提出合理性药学服务建议，协助医师制定个体化用药方案。结果病人 HD-MTX化疗后出现早期排泄延迟，临床药师分析认为其原因可能与尿 pH值过低、药物相互作用、肾功能损伤、第三空间存在、低蛋白血症等因素相关；之后，病人甲氨蝶呤血药浓度出现波动现象，临床药师分析可能与利尿药的使用、肾功能进一步恶化及第三空间的存在相关。通过以上分析，临床药师及时建议充分碱化尿液促进甲氨蝶呤排泄；停用可能导致甲氨蝶呤排泄延迟的药物泮托拉唑，改用雷尼替丁继续治疗；避免使用磺胺类药物以免排泄延迟及肾功能损伤进一步加重等。在药师的积极参与下，病人成功救治，顺利出院。结论 HD-MTX排泄延迟的发生及血药浓度变化受多种因素影响，临床药师参与临床药物治疗，有助于促进临床合理用药，保障病人用药安全。 |
| 英文摘要: |
| Objective To promote safe and rational use of high-dose methotrexate(HD-MTX) in clinical by clinical pharmacists par? ticipating in the treatment of patients with delayed excretion of HD-MTX. Methods Clinical pharmacists of Anhui Provincial Cancer Hospital implemented whole-process pharmaceutical care on a patient with delayed excretion of HD-MTX admitted in October 2018,analysed the reasons for delayed excretion of MTX and plasma concentration fluctuations, put forward reasonable pharmaceutical careadvice, assisted physicians to make individualized medication. Results The patient had early delayed excretion after HD-MTX che? motherapy, clinical pharmacist analyzed that the cause might be related to factors such as low urine pH, drug interactions, renal dam?age, the existence of the third space, and hypoproteinemia.After that, the blood concentration of MTX fluctuated, clinical pharmacistsanalyzed that it might be related to the use of diuretics, further deterioration of renal function and the existence of the third space.Basedon the above analyses, clinical pharmacists promptly suggested the following: fully alkalize urine to promote MTX excretion; discontinu?ation of pantoprazole,which may cause delayed excretion of MTX, and switch to ranitidine to continue treatment; avoid using sulfon?amides to avoid further delayed excretion and renal injury. With the active participation of pharmacists, the patient was rescued suc?cessfully and discharged smoothly. Conclusion The occurrence of delayed excretion of HD-MTX and the change of plasma concentra?tion are affected by many factors, clinical pharmacists participate in clinical drug therapy is helpful to promote rational clinical druguse and ensure the medication safety of patients. |
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