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冠状动脉介入术后发生肝素诱导的血小板减少症抗栓治疗的药学监护

管文婕,  陈慧慧,  汪涛,  张晨晨,  陈延杰,  朱捷

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文章导航 > 药学实践与服务  > 2019 >  37(4): 370-374
管文婕, 陈慧慧, 汪涛, 张晨晨, 陈延杰, 朱捷. 冠状动脉介入术后发生肝素诱导的血小板减少症抗栓治疗的药学监护[J]. 药学实践与服务, 2019, 37(4): 370-374. doi: 10.3969/j.issn.1006-0111.2019.04.017
引用本文: 管文婕, 陈慧慧, 汪涛, 张晨晨, 陈延杰, 朱捷. 冠状动脉介入术后发生肝素诱导的血小板减少症抗栓治疗的药学监护[J]. 药学实践与服务, 2019, 37(4): 370-374. doi: 10.3969/j.issn.1006-0111.2019.04.017
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GUAN Wenjie, CHEN Huihui, WANG Tao, ZHANG Chenchen, CHEN Yanjie, ZHU Jie. Pharmaceutical care of antithrombotic therapy for heparin-induced thrombocytopenia after percutaneous coronary intervention[J]. Journal of Pharmaceutical Practice and Service, 2019, 37(4): 370-374. doi: 10.3969/j.issn.1006-0111.2019.04.017
Citation: GUAN Wenjie, CHEN Huihui, WANG Tao, ZHANG Chenchen, CHEN Yanjie, ZHU Jie. Pharmaceutical care of antithrombotic therapy for heparin-induced thrombocytopenia after percutaneous coronary intervention[J]. Journal of Pharmaceutical Practice and Service, 2019, 37(4): 370-374. doi: 10.3969/j.issn.1006-0111.2019.04.017
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冠状动脉介入术后发生肝素诱导的血小板减少症抗栓治疗的药学监护

doi: 10.3969/j.issn.1006-0111.2019.04.017

  • 中国人民解放军联勤保障部队第九〇一医院药剂科, 安徽 合肥 230031

基金项目: 国家科技支撑计划（2013BAI06B04）

Pharmaceutical care of antithrombotic therapy for heparin-induced thrombocytopenia after percutaneous coronary intervention

  • Department of Pharmacy, Hospital 901 of the Joint Logistics Support Force of PLA, Hefei 230031, China

  • 摘要: 目的 探讨临床药师在急性心肌梗死（AMI）患者经皮冠脉介入术（PCI）后发生肝素诱导的血小板减少症（heparin-induced thrombocytopenia，HIT）抗栓治疗方案制定及药学监护。 方法 临床药师利用急性冠脉综合征临床风险评分（GRACE）及抗血小板、抗凝治疗出血风险评分（Crusade）进行死亡风险及缺血、出血风险评估，及时调整抗栓治疗方案。出现HIT后分析血小板减少的原因及凝血功能，确定可能的相关药物因素，选择阿加曲班替代抗凝治疗，并及时监测活化部分凝血活酶时间（APTT）进行剂量调整。从药物的作用机制，不良反应，安全经济性，阐述出院带药选择华法林对患者的用药优势。 结果 选择阿加曲班替代抗凝治疗，维持双联抗血小板（阿司匹林+氯吡格雷）方案，患者情况控制平稳，未出现出血及血栓栓塞并发症，顺利出院。 结论 临床药师需要充分了解药理学及药动学变化，可协助临床发现药物治疗相关问题。同时需加强监测，以便及时调整用药方案，提高临床用药的安全性和合理性，为患者提供更好的药学服务。
    Abstract: Objective To explore clinical pharmacists' role in antithrombotic therapy for acute myocardial infarction (AMI) inpatients with heparin-induced thrombocytopenia (HIT) after percutaneous coronary intervention (PCI). Methods Clinical pharmacists used the acute coronary syndrome clinical risk score (GRACE) and anti-platelet and anticoagulant treatment bleeding risk score (Crusade) to assess the risk of ischemia and bleeding in order to adjust the dose for antiplatelet therapy.The causes of thrombocytopenia and coagulation were evaluated.The possible medication related factors were identified for HIT patient.Argatroban was used to replace anticoagulant therapy and APTT was closely monitored in order to adjust dose in a timely manner.Warfarin was recommended for the discharged patients based on the mechanism of action,adverse reactions,safety and economics. Results No bleeding or thromboembolic complications was observed on the patient with argatroban for anticoagulant therapy and aspirin plus clopidogrel as maintenance therapy. Conclusion With good understanding in pharmacology and pharmacokinetics,clinical pharmacists can help doctors to solve the problems related to drug therapy in time.Therefore,better pharmaceutical care can be provided to patients with improved medication safety and rationality.
  • [1] 中华医学会心血管病学分会,中国心脑血管病杂志编辑委员会.急性ST段抬高型心肌梗死诊断和治疗指南[J],中华心脑血管病杂志,2015,43(5):380-386.
    [2] SALTER B S,WEINER M M,TRINH M A,et al.Heparin-induced thrombocytopenia:A comprehensive clinical review[J].J Am Coll Cardiol,2016,67(21):2519-2532.
    [3] 黄震华.肝素诱发的血小板减少症的诊断和治疗进展[J].中国新药与临床杂志,2017,36(1):11-15.
    [4] BRYANT A,LOW J,AUSTIN S,et al.Timely diagnosis and management of heparin-induced thrombocytopenia in a frequent request,low incidence single centre using clinical 4T's score and particle gel immunoassay[J].Br J Haematol,2008,143(5):721-726.
    [5] HRON G,KNUTSON F,THIELE T,et al.Alternative diagnosis to heparin-induced thrombocytopenia in two critically ill patients despite a positive PF4/heparin-antibody test[J].Ups J Med Sci,2013,118(4):279-284.
    [6] 廖敏辉,李平,刘永刚,等.GRACE与CRUSADE危险评分的相关性研究[J].中国药师,2015,18(3):441-443.
    [7] American Society of Hematology.2013 Clinical Practice Guideline on the Evaluation and Management of Adults with Suspected Heparin-Induced Thrombocytopenia(HIT)[EB/OL].(2013-12-02)[2015-10-15].http://www.hematology.org/.
    [8] COSMI B.Current management of heparin-induced thrombocytopenia[J].Expert Rev Hematol,2015,8(6):837-849.
    [9] ALATRI A,ARMSTRONG A E,GREINACHER A,et al.Results of a consensus meeting on the use of argatroban in patients with heparin-induced thrombocytopenia requiring antithrombotic therapy - a European Perspective[J].Thromb Res,2012,129(4):426-433.
    [10] LEWIS B E,MATTHAI W H Jr,COHEN M,et al.Argatroban anticoagulation during percutaneous coronary intervention in patients with heparin-induced thrombocytopenia[J].Catheter Cardiovasc Interv,2002,57(2):177-184.
    [11] LINKINS L A,DANS A L,MOORES L K,et al.Treatment and prevention of heparin-induced thrombocytopenia:antithrombotic therapy and prevention of thrombosis,9th ed:American college of chest physicians evidence-based clinical practice guidelines[J].Chest,2012,141(2 Suppl):e495S-e530S.
    [12] 汤丽萍,赵卫国.利伐沙班治疗急性肺栓塞疗效分析[J].临床肺科杂志,2014,19(10):1780-1782.
    [13] KEARON C,AKL E A,COMEROTA A J,et al.Antithrombotic therapy for VTE disease:antithrombotic therapy and prevention of thrombosis,9th ed:American college of chest physicians evidence-based clinical practice guidelines[J].Chest,2012,141(2 Suppl):e419S-e496S.
    [14] 中华医学会外科学分会血管外科学组.深静脉血栓形成的诊断和治疗指南[J].中华普通外科杂志,2017,32(9):807-809.
    [15] 张旭光.氯吡格雷致白细胞及血小板减少[J].药物不良反应杂志,2010,12(1):54-55.
    [16] DEWILDE W J,OIRBANS T,VERHEUGT F W,et al.Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention:An open-label,randomised,controlled trial[J].Lancet,2013,381(9872):1107-1115.
    [17] 中华医学会心血管病学分会,中国老年学学会心脑血管病专业委员会.华法林抗凝治疗的中国专家共识[J].中华内科杂志,2013,52(1):76-82.
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  • 收稿日期:  2019-03-01
  • 修回日期:  2019-05-24

冠状动脉介入术后发生肝素诱导的血小板减少症抗栓治疗的药学监护

doi: 10.3969/j.issn.1006-0111.2019.04.017
  • 中国人民解放军联勤保障部队第九〇一医院药剂科, 安徽 合肥 230031
    • 基金项目:  国家科技支撑计划（2013BAI06B04）
  • 收稿日期: 2019-03-01
  • 修回日期: 2019-05-24

摘要: 目的 探讨临床药师在急性心肌梗死（AMI）患者经皮冠脉介入术（PCI）后发生肝素诱导的血小板减少症（heparin-induced thrombocytopenia，HIT）抗栓治疗方案制定及药学监护。 方法 临床药师利用急性冠脉综合征临床风险评分（GRACE）及抗血小板、抗凝治疗出血风险评分（Crusade）进行死亡风险及缺血、出血风险评估，及时调整抗栓治疗方案。出现HIT后分析血小板减少的原因及凝血功能，确定可能的相关药物因素，选择阿加曲班替代抗凝治疗，并及时监测活化部分凝血活酶时间（APTT）进行剂量调整。从药物的作用机制，不良反应，安全经济性，阐述出院带药选择华法林对患者的用药优势。 结果 选择阿加曲班替代抗凝治疗，维持双联抗血小板（阿司匹林+氯吡格雷）方案，患者情况控制平稳，未出现出血及血栓栓塞并发症，顺利出院。 结论 临床药师需要充分了解药理学及药动学变化，可协助临床发现药物治疗相关问题。同时需加强监测，以便及时调整用药方案，提高临床用药的安全性和合理性，为患者提供更好的药学服务。

English Abstract

管文婕, 陈慧慧, 汪涛, 张晨晨, 陈延杰, 朱捷. 冠状动脉介入术后发生肝素诱导的血小板减少症抗栓治疗的药学监护[J]. 药学实践与服务, 2019, 37(4): 370-374. doi: 10.3969/j.issn.1006-0111.2019.04.017
引用本文: 管文婕, 陈慧慧, 汪涛, 张晨晨, 陈延杰, 朱捷. 冠状动脉介入术后发生肝素诱导的血小板减少症抗栓治疗的药学监护[J]. 药学实践与服务, 2019, 37(4): 370-374. doi: 10.3969/j.issn.1006-0111.2019.04.017
shu
GUAN Wenjie, CHEN Huihui, WANG Tao, ZHANG Chenchen, CHEN Yanjie, ZHU Jie. Pharmaceutical care of antithrombotic therapy for heparin-induced thrombocytopenia after percutaneous coronary intervention[J]. Journal of Pharmaceutical Practice and Service, 2019, 37(4): 370-374. doi: 10.3969/j.issn.1006-0111.2019.04.017
Citation: GUAN Wenjie, CHEN Huihui, WANG Tao, ZHANG Chenchen, CHEN Yanjie, ZHU Jie. Pharmaceutical care of antithrombotic therapy for heparin-induced thrombocytopenia after percutaneous coronary intervention[J]. Journal of Pharmaceutical Practice and Service, 2019, 37(4): 370-374. doi: 10.3969/j.issn.1006-0111.2019.04.017
shu

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