肺腺癌合并左肺阻塞性肺炎及左下肢深静脉血栓患者治疗药学监护_钱春艳_宋惠珠_蔡小.pdf

中国药物应用与监测 2016年12月 第13卷 第6期 Chinese Journal of Drug Application and Monitoring, Vol.13, No.6, December 2016 肺腺癌合并左肺阻塞性肺炎及左下肢深静脉血栓患者治疗药学监护 钱春艳 1，宋惠珠 2，蔡小军 （2 1.常州市第一人民医院药学部，江苏 常州 213003；2.南京医科大学附属无锡市人民医院药学部，江苏 无锡 214023） [ 摘要]　1 例中年女性患者，因肺癌化疗入院，入院诊断为左肺腺癌（T4N3M0，Ⅲ b 期），左侧阻塞性肺炎，左下肢深静脉血 栓。因患者出现下肢深静脉血栓，先后使用低分子肝素和华法林治疗，临床药师评估了低分子肝素和华法林的重叠使用时 间，并通过动态测定INR调整华法林的用量。因甲地孕酮分散片（宜利治）可促进深静脉血栓形成，建议停用。同时，临床药 师分析了血栓形成及加重可能是因左下肺阻塞性肺炎治疗所使用的抗生素及肺癌治疗应用的化疗药与华法林的相互作用所 致，提示医生予以关注，并就可能影响华法林血药浓度的药物和食物以及INR监测等对患者进行出院教育。 [关键词]　肺癌；深静脉血栓；抗凝治疗；华法林；药学监护 [中图分类号]　R969.4 [文献标识码]　A　 [文章编号]　1672 – 8157(2016)06 – 0349 – 04 Pharmaceutical care on a patient with lung adenocarcinoma, left lung obstructive pneumonia and left lower extremity deep vein thrombosis QIAN Chun-yan1, SONG Hui-zhu2, CAI Xiao-jun2(1. Department of Pharmacy, the First Peoples Hospital of Changzhou, Changzhou 213003, China; 2. Department of Pharmacy, Wuxi Peoples Hospital Attached to Nanjing Medical University, Wuxi 214023, China) [ABSTRACT]　One case of middle-aged female patient was admitted to hospital due to left lung adenocarcinoma. Her admitting diagnosis were left lung adenocarcinoma, left lung obstructive pneumonia, left lower extremity deep vein thrombosis. Low molecular weight heparin and warfarin were successively given to the patient for lower limb venous thrombus. Clinical pharmacist evaluated the rationality of the overlapping time of the low molecular weight heparin and warfarin, and adjusted the dosage of warfarin according to INR values. Megestrol acetate dispersible tablets was withdrawn because it might contribute to the formation of deep vein thrombosis. Clinical pharmacists analyzed that developed and aggravated thrombosis might be resulted in the combining use of antibiotics, chemotherapeutic agents and warfarin, which was forwarded to doctors. Discharge education was offered to