中图分类号 R969.3文献标志码 A文章编号 1001-0408（2019）17-2388-06
DOI 10.6039/j.issn.1001-0408.2019.17.17
摘 要 目的：探讨药师如何通过药物治疗管理（Medication therapy management，MTM）结合药物基因检测为患者提供个体化药学服务，以促进临床合理用药。方法：以1例服用华法林钠片导致急性上消化道出血的老年共病患者（该患者有2型糖尿病、高血压史，入院2个月前行冠状动脉旁路移植术，半个月前患泌尿系统感染）为例，回顾性分析患者住院前后药物治疗过程，结合CYP2C9*3、VKORC1-1639基因分型检测，评估华法林钠片个体化给药剂量，针对急性上消化道出血及患者所有用药进行MTM，制订个体化药物治疗方案。结果：华法林CYP2C9*3、VKORC1-1639的基因分型测定提示患者为超慢代谢型，推荐华法林给药剂量应为0.86～1.86 mg/d，结合急性上消化道出血情况进行MTM分析，患者使用华法林钠片3.0 mg/d、用药依从性差、疾病状态及共病多药联合可能是导致急性上消化道出血的主要原因，患者停用华法林及对症治疗后临床消化道出血好转，抗凝药物更换为利伐沙班片10 mg/d。通过对患者所有用药进行MTM，药物重整结果显示，停用盐酸地尔硫 片、阿莫西林克拉维酸钾分散片、复合维生素片，將降糖药物格列美脲片更换格列喹酮片，冠状动脉旁路移植术后用药酒石酸美托洛尔片更换为比索洛尔片，质子泵抑制剂艾司奥美拉唑肠溶片更换为泮托拉唑钠肠溶胶囊。结论：MTM结合药物基因检测的药学服务模式可指导临床安全合理用药，实现个体化药学服务，提高患者依从性，预防药品不良反应相关问题。
关键词 华法林;药物治疗管理;药物基因检测;个体化药学服务
Application of Medication Therapy Management Combined with Medicine Gene Detection in Individualized Pharmaceutical Care of An Elderly Patient with Warfarin-induced Acute Upper Gastrointestinal Hemorrhage
WANG Lan1，MAO Qiantai1，ZHANG Xiaoning2，JI Zhaoshuai1，AI Chao1（1.Beijing Tsinghua Changgung Hospital， School of Clinical Medicine， Tsinghua University， Beijing 102218，China;2.School of Medicine，Tsinghua University，Beijing 100084，China）
ABSTRACT OBJECTIVE： To investigate how pharmacists provide through individualized pharmaceutical care for patients medication therapy management（MTM） combined with medicine gene detection， and to promote rational drug use in clinic.METHODS： A case of elderly comorbidity with acute upper gastrointestinal hemorrhage caused by Warfarin sodium tablets was taken as an example. The patient had a history of type 2 diabetes mellitus and hypertension. Coronary artery bypass grafting was performed two months before admission， and urinary tract infection occurred half a month ago. Medication therapy course was analyzed retrospectively before and after hospitalization; based on gene typing detection of CYP2C9*3 and VKORC1-1639， the individualized dose of Warfarin sodium tablets was evaluated. MTM was perfomed for acute upper gastrointestinal hemorrhage and all medication of patient to formulate individualized medication scheme. RESULTS： The genotyping of warfarin CYP2C9*3 and VKORC1-1639 indicated that the patients were of super slow metabolic type. The recommended dosage of warfarin should be 0.86-1.86 mg/d. Based on MTM analysis of acute upper gastrointestinal hemorrhage， the main causes of acute upper gastrointestinal hemorrhage were Warfarin sodium tablets 3.0 mg/d， poor drug compliance， disease status and co-morbidity and multi-drug combination. Clinical gastrointestinal hemorrhage of the patients were improved after drug withdrawal， anticoagulant drugs was changed into Rivaroxaban tablet，10 mg/d. Through MTM for all drug use in the patient， results of medication reorganization showed that Diltiazem hydrochloride tablet， Amoxicillin/clavulanate potassium dispersible tablet， Compound vitamin tablet were stopped; hypoglycemic drug Glimepiride tablet was changed into Gliquidone tablet; Metoprolol tartrate tablet was changed into Bisoprolol tablet after coronary artery bypass graft; proton pump inhibitor Esomeprazole enteric-coated tablet was changed into Pantoprazole sodium enteric-coated capsule. CONCLUSIONS： The pharmaceutical care mode of MTM combined with medicine gene detection can guide rational drug use in clinic， realize individualized pharmaceutical care， improve patient compliance and prevent problems related to adverse drug reactions.