1例淋巴瘤患者大剂量甲氨蝶呤消除异常的药学监护  

Pharmaceutical Care on A Lymphoma Patient with High-dose Methotrexate Elimination Abnormalities

作　　者：钟桂珍 刘澍[1] 李金兰 陈卓佳[1] 梁蔚婷[1] 黄红兵[1] 刘韬[1] ZHONG Guizhen;LIU Shu;LI Jinlan;CHEN Zhuojia;LIANG Weiting;HUANG Hongbing;LIU Tao(Department of Pharmacy,Sun Yat-sen University Cancer Center,Guanzhou,Guangdong 510060,China;Hunan Cancer Hospital,Changsha,Hunan 410031,China)

机构地区：[1]中山大学肿瘤防治中心药学部,广东广州510060 [2]湖南省肿瘤医院药学部,湖南长沙410031

出　　处：《今日药学》2022年第11期867-870,共4页Pharmacy Today

基　　金：国家自然科学基金资助项目(81730103);广东省医学科学技术研究基金资助项目(A2021159);广东省医院协会药学科研专项基金(2021YXZD03)。

摘　　要：目的探讨临床药师在大剂量甲氨蝶呤治疗后发生消除异常时实施药学监护的模式、方法与作用。方法临床药师参与1例淋巴瘤患者出现的大剂量甲氨蝶呤消除异常及严重不良反应(皮疹、口腔溃疡、Ⅳ度骨髓抑制)的对症处理及解毒过程,进行治疗药物浓度监测,制定水化、碱化、亚叶酸钙解救等方案,对甲氨蝶呤消除异常的情况积极查因,并进行医嘱重整。结果临床药师分析可能是肾功能损伤、高BMI/BSA、低白蛋白、药物相互作用联合导致患者甲氨蝶呤消除异常,在全程个体化药学监护下,患者解毒成功,皮疹消退、口腔溃疡好转、骨髓抑制恢复。结论临床药师建立全方位、个体化的大剂量甲氨蝶呤药学监护路径,对临床安全用药意义重大。OBJECTIVE To investigate the mode,method and effect of clinical pharmacists in implementing pharmacological care when eliminating abnormalities occur after treatment with high-dose methotrexate.METHODS The clinical pharmacists participated in the symptomatic treatment and detoxification process of high-dose methotrexate elimination abnormalities and serious adverse reactions(rash,mouth ulcers,grade four bone marrow suppression)in a patient with lymphoma,performed therapeutic drug monitoring,formulated hydration,alkalinization,calcium folinate rescue and so on,actively investigated the causes of methotrexate elimination abnormalities,and rearrange medical order.RESULTS Clinical pharmacists analyzed may be impairment of renal function,high BMI/BSA,low albumin,drug interaction combined to cause the patient’s methotrexate elimination abnormalities.Under the whole process of individualized pharmacy supervision,the patient was successfully detoxified,the rash subsided,the mouth ulcer improved,and the bone marrow suppression recovered.CONCLUSION The establishment of a comprehensive and individualized pharmacological monitoring path for high-dose methotrexate by clinical pharmacists is of great significance to the safety of clinical medication.

关 键 词：大剂量甲氨蝶呤 治疗药物浓度监测 药学监护 消除延迟 皮疹 骨髓抑制 

分 类 号：R95[医药卫生—药学]