1例重度肝硬化伴肺曲霉病患者伏立康唑用药方案调整实践  

Adjustment of Treatment Regimen of Voriconazole in Severe Cirrhosis Complicated with Pulmonary Aspergillosis:A Case Report

作　　者：康晓凤 黄炎 吕立勋 李殊 张金凤 KANG Xiaofeng;HUANG Yan;LYU Lixun;LI Shu;ZHANG Jinfeng(College of Pharmacy,North China University of Science and Technology,Tangshan,Hebei,China 063210;Affiliated Hospital of North China University of Science and Technology,Tangshan,Hebei,China 063000)

机构地区：[1]华北理工大学药学院,河北唐山063210 [2]华北理工大学附属医院,河北唐山063000

出　　处：《中国药业》2025年第2期125-128,I0001,共5页China Pharmaceuticals

基　　金：河北省卫生健康委员会医学科学研究课题[20191118]。

摘　　要：目的为重度肝硬化患者的个体化用药提供依据。方法回顾医院收治的1例重度肝硬化(Child-Pugh分级为C级)伴肺曲霉病感染患者的用药经过。患者入院第6天因咳嗽加重,经胸部X线摄片确诊双侧胸部肺炎,予莫西沙星、头孢哌酮舒巴坦抗感染,效果不佳,并反复发热,9 d后因咳痰取痰标本培养;入院第21天经验性给予伏立康唑,2 d后痰培养发现烟曲霉,使用伏立康唑期间发热等症状好转,但肝功能(转氨酶、总胆红素)严重异常。请临床药师会诊,考虑为伏立康唑导致的肝损害,曾建议行疾病相关CYP2C19基因多态性检测,家属未同意;查阅国外指南及药品说明书,建议监测血药浓度(最高达25.89μg/mL)及调整伏立康唑剂量[负荷剂量(400 mg,12 h 1次)不变,维持剂量减半(100 mg)且隔日给药1次]。结果临床医师采纳临床药师建议,患者伏立康唑血药浓度及肝功能逐渐恢复正常,病情好转出院。结论严重肝功能不全患者应权衡利弊使用伏立康唑,确需使用时可予减量治疗方案,并建议监测血药浓度,并据此调整治疗方案。最好还能做CYP2C19基因多态性检测。Objective To provide a basis for individualized medication for patients with severe cirrhosis.Methods The medication process of a patient with severe cirrhosis(Child-Pugh grade C)complicated with pulmonary aspergillosis admitted to the hospital was retrospectively analyzed.On the 6th day of admission,the patient′s cough worsened and he was diagnosed with bilateral chest pneumonia through chest X-ray;moxifloxacin and cefoperazone sulbactam were given for anti-infection,but the effect was not satisfactory and he experienced recurrent fever;the patient′s sputa were collected and cultured due to expectoration after 9 d.On the 21st day of admission,the patient was given voriconazole empirically;Aspergillus fumigatus was detected through sputum culture after 2 d;the patient′s symptoms such as fever improved during the use of voriconazole,while the liver function(transaminase,total bilirubin)was severely abnormal.After pharmaceutical consultation,the clinical pharmacists considered that the above adverse reactions were the liver damage induced by voriconazole,and once suggested performing disease-related CYP2C19 gene polymorphism testing,but the family did not agree.Based on foreign guidelines and drug instruction,clinical pharmacists suggested monitoring the blood concentration(up to 25.89μg/mL)and adjusting the dose of voriconazole[with unchanged loading dose(400 mg,once every 12 h);half of the maintenance dose(100 mg),once every other day].Results The clinical physicians adopted clinical pharmacists′suggestions,and then the patient′s voriconazole blood concentration and liver function gradually returned to normal,and he discharged after condition improvement.Conclusion For the patients with severe liver dysfunction,voriconazole should be considered comprehensively before use.If necessary,clinical physicians can provide a decreased-dosage treatment regimen,monitor the blood concentration,and adjust the treatment regimen accordingly;it is best to also perform the CYP2C19 gene polymorphism testing.

关 键 词：伏立康唑 治疗药物监测 重度肝硬化 肺曲霉病 个体化用药 

分 类 号：R969.3[医药卫生—药理学]