摘要
目的为糖尿病合并肝移植术后免疫抑制剂致高脂血症患者的临床合理用药和药学监护提供参考。方法临床药师参与1例糖尿病合并疑似肝移植术后免疫抑制剂致高脂血症患者的治疗过程。由于患者血糖控制不佳,临床药师与医生共同调整降糖方案为三餐前分别皮下注射赖脯胰岛素注射液18、12、16单位,睡前皮下注射甘精胰岛素注射液16单位;由于患者发生高脂血症,临床药师结合相关指南并通过梳理其免疫抑制剂剂量调整时间轴及血脂水平变化趋势,明确血脂异常升高的可能诱因为免疫抑制剂,建议给予瑞舒伐他汀钙片5 mg,qd降脂治疗,分别将吗替麦考酚酯胶囊和他克莫司胶囊降至500 mg,bid和2 mg,bid,并开展用药宣教及药学监护。结果医生采纳临床药师的建议。患者经治疗后,血糖、血脂水平明显改善,准予带药出院。结论临床药师通过建议加用他汀类药物、调整免疫抑制剂剂量、开展药学监护等药学服务手段,优化患者个体化用药方案,保障了患者用药的安全性和有效性。
OBJECTIVE To provide a reference for clinically rational drug use and pharmaceutical care for patients with diabetes complicated with hyperlipidemia induced by immunosuppressive agents after liver transplantation.METHODS Clinical pharmacists participated in the treatment of a patient with diabetes complicated with suspected hyperlipidemia induced by immunosuppressive agents after liver transplantation.Due to the poor glucose control of the patient,the clinical pharmacists assisted the doctor in adjusting the glycemic control plan:subcutaneous injection of 18,12 and 16 units of Insulin lispro injection before meals,and subcutaneous injection of 16 units of Insulin glargine injection before bedtime.Due to the occurrence of hyperlipidemia in the patient,clinical pharmacists clarified the possible cause of abnormal blood lipid elevation was using immunosuppressants by reviewing the timeline of dose adjustment of immunosuppressive agents and changes in blood lipid levels based on relevant guidelines.Clinical pharmacists suggested using Rosuvastatin calcium tablets 5 mg,qd for lipid-lowering treatment,reducing the dosage of Mycophenolate mofetil capsules and Tacrolimus capsules to 500 mg,bid and 2 mg,bid,respectively.Medication education and pharmaceutical care were also carried out.RESULTS The doctor adopted the advice of the clinical pharmacists.After treatment,the levels of blood glucose and blood lipid in the patient improved,and he was allowed to be discharged with medication.CONCLUSIONS Clinical pharmacists provide pharmaceutical services such as recommending the addition of statins,adjusting the dosage of immunosuppressive agents,and conducting pharmaceutical care to optimize individualized medication plans for patients and ensure the safety and effectiveness of medication.
作者
李惟妙
宋荣景
张春燕
黄琳
张晓红
LI Weimiao;SONG Rongjing;ZHANG Chunyan;HUANG Lin;ZHANG Xiaohong(Dept.of Pharmacy,Peking University People’s Hospital,Beijing 100044,China;School of Pharmacy,Peking University,Beijing 100191,China)
出处
《中国药房》
CAS
北大核心
2024年第18期2310-2314,共5页
China Pharmacy
基金
北京大学人民医院研究与发展基金资助项目(No.RDY2021-28)。
关键词
免疫抑制剂
肝移植术后
高脂血症
糖尿病
临床药师
药学监护
immunosuppressive agents
after liver trans-plantation
hyperlipidemia
diabetes
clinical pharmacist
pharmaceutical care
