临床药师参与6例肝素诱导血小板减少症的治疗实践

目的 探讨肝素诱导血小板减少症(Heparin-induced thrombocytopenia, HIT)的治疗方案及临床药师在治疗中发挥的作用。方法 临床药师参与6例深静脉血栓防治患者肝素诱导血小板减少的治疗和药学监护,从患者的临床情况及用药史等进行分析,协助医师制定治疗方案。结果 临床医师采纳建议,6例患者均将肝素调整为利伐沙班,血小板计数完全恢复正常,平均随访6个月,未出现活动性出血和新发血栓形成。结论 临床药师参与临床实践,优化抗凝药物治疗方案,为保障用药安全发挥了积极作用。     

肝素致血小板减少症

在美国,肝素钠注射剂产品的标签上最近补充了一则警告语,提示肝素致血小板减少症(HIT)可能延迟发生,进一步建议用此类产品时应密切监测不同程度的血小板减少症出现,若血小板计数跌至100000/mm3以下或血栓形成复发,则此肝素产品应立即停用,考虑改用其他抗凝药。先前肝素产品标签上也有关于致血小板减少症的警告语,而此次修订的新警告语还强调,HIT为一种抗体介导的严重不良反应,由不可逆的血小板凝聚所致,并可进而发展为静脉和动脉血栓形成,即所谓肝素致血小板减少与血栓形成(HITT)。这些新警告语已在近期的美国FDA MedWatch网站公布。…     

血液透析中普通肝素与低分子肝素致血小板减少症分析

肝素是血液透析中体外抗凝治疗中最常用的抗凝剂,随着肝素在临床中的广泛应用,肝素诱导的血小板减少症已引起人们的高度重视,如若伴有血栓形成则称为肝素诱导的血小板减少症伴血栓形成,其致残、致死率很高[1]。     

临床药师参与1例药源性重度血小板减少症的病例分析

目的 探讨急性心肌梗死患者经皮冠脉介入治疗术（PCI）后发生严重药源性血小板减少症（DITP）的相关药物。方法 临床药师对该例患者的用药情况进行分析,协助制定药源性血小板减少症的对症治疗方案并全程实施药学监护。结果 临床药师判定替罗非班为致血小板减少症的可疑药物。经对症治疗后,患者血小板逐渐恢复正常,病情缓解出院。结论 临床药师参与药源性血小板减少症患者的治疗与监护,可减少不良反应的发生,保障患者的用药安全。     

依诺肝素致重度Ⅱ型血小板减少症患者的药学监护

临床药师参与1例重度Ⅱ型依诺肝素诱导性血小板减少症（heparin-induced thrombocytopenia,HIT）患者的诊治,通过采用病例分析和文献复习的方法,协助治疗方案的审核、调整和优化,为患者提供优质的药学监护服务,促进药物的合理使用。临床医师及药师应关注肝素类药物引起的血小板减少症,治疗期间应加强血小板计数的监测和出血反应的监护。     

临床药师对心血管围术期发生肝素诱导性血小板减少症的用药监护

探讨临床药师参与心血管围术期抗凝治疗发生肝素诱导性血小板减少症的应对模式及监护要点。临床药师参与1例主动脉夹层患者发生肝素诱导性血小板减少症及围术期抗凝治疗的过程,并提出治疗与监护建议。通过4Ts评估法及相关实验室检测,关注抗凝药物的不良反应和更换方案,避免心血管不良事件发生。临床药师有必要开展心血管围术期抗凝药物的药学监护工作,优化抗凝治疗方案,确保临床用药安全。     

冠状动脉介入术后肝素诱导的血小板减少症1例

患者,女,70岁,因“阵发性胸闷、胸痛7年,加重2周”入院。入院查体：BP160／90mmHg（1mmHg=0．133kPa）,全身皮肤黏膜无皮疹及出血点,双肺呼吸音清晰,未闻及干湿性哕音。心率68次／min,律齐,未闻及异常心音及病理性杂音。腹软,无压痛,双下肢无水肿。实验室检查：血常规：     

临床药师参与2例药源性血小板减少症诊治案例分析

目的:为抗栓治疗诱发药源性血小板减少症患者药学监护提供参考。方法:临床药师通过参与2例分别由低分子肝素、盐酸替罗非班致药源性血小板减少症典型案例分析,给予药学建议,分别为换用磺达肝癸钠注射液2.5 mg,ih,qd,同时给予甲泼尼龙200 mg,输注血小板2 u;停用盐酸替罗非班,口服阿司匹林、氯吡格雷,连续3 d分别输注血小板1 u、甲泼尼龙200 mg。结果:临床药师协助判断血小板减少症的病因并给予适当处理后患者血小板逐渐恢复正常,病情缓解出院。结论:临床药师参与抗栓诱发药源性血小板减少症患者的药学监护,能有效改善患者预后,保障患者的用药安全。     

卵巢癌患者应用低分子肝素致血小板减少症的病例分析

临床药师通过参与1例卵巢癌合并血栓患者药物治疗过程,综合分析其血小板减少的原因,考虑可能为低分子肝素引起的药物不良反应。临床药师协助临床医师为患者制定个体化治疗方案,患者血小板逐渐恢复。临床药师在保证患者药物治疗的安全、有效方面充分发挥了重要的作用。     

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

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。     

Ⅱ型肝素诱导血小板减少症的危险因素分析

目的：分析我院心内科患者发生II型肝素诱导血小板减少症的危险因素。方法：收集筛选我院心内科自2004年1月—2013年7月间使用肝素抗凝治疗过程中产生II型肝素诱导的血小板减少症的病例进行临床资料分析,根据使用肝素后血小板数减少的比例以50%为界,将患者分为明显减少组和未明显减少组。主要分析指标为性别、年龄、肝素制剂、肝素治疗时间、合并使用抗血小板药物、使用肝素前血小板计数、内生肌酐清除率、丙氨酸转氨酶以及谷氨酸转氨酶。结果：131例患者中使用肝素类型为普通肝素（介入手术过程中使用）和低分子肝素,其中血小板明显减少为32例,血小板未明显减少为99例。统计结果显示年龄和用药前血小板计数存在统计学差异。结论：年龄和用药前血小板计数可能为II型肝素诱导产生血小板减少的危险因素。     

Argatroban use in heparin-induced thrombocytopenia

Background: Heparin-induced thrombocytopenia (HIT) is a serious, life-threatening complication which occurs in 1 – 3% of patients receiving heparin. Patients with untreated HIT have an up to 50% risk of developing life- and limb-threatening thromboembolic complications. Treatment is based upon clinical suspicion, stopping heparin therapy and initiation of anticoagulation with a rapidly acting alternative non-heparin anticoagulant, such as argatroban – a hepatically excreted direct thrombin inhibitor which is effective in the treatment of HIT. Objective: To summarize the pharmacological and clinical data, and discuss the impact of argatroban in the current treatment of HIT. Methods: A literature search was performed with the aid of Pubmed and Google. Search parameters of ‘argatroban’, ‘heparin-induced thrombocytopenia’ and ‘treatment’ were input into both search engines. Conclusion: Argatroban is a safe and effective treatment for HIT. In patients taking other hepatically cleared medications, lower initial doses may have to be used to avoid over-anticoagulation.     

Treatment of heparin-induced thrombocytopenia in cardiovascular patients

Heparin-induced thrombocytopenia (HIT) is an antibody-mediated syndrome associated with heparin exposure, a falling platelet count and a high risk of thrombosis. Cardiovascular patients are at increased risk of HIT due to wide use of heparin in this population. Should HIT be suspected, heparin must be avoided in most situations, and anticoagulation with an alternative anticoagulant should be instituted. Preferred agents include the direct thrombin inhibitors argatroban and lepirudin, whilst bivalirudin or desirudin (other direct thrombin inhibitors) can be used in some situations. The indirect thrombin inhibitors, danaparoid and fondaparinux, can also be considered at times. These agents and their use in cardiac patients, including patients with acute coronary syndrome, percutaneous coronary interventions, acute ST elevation myocardial infarction or cardiac surgery, will be reviewed.     

Argatroban therapy in heparin-induced thrombocytopenia

Argatroban is a direct thrombin inhibitor approved for anticoagulation in heparin-induced thrombocytopenia (HIT; in several countries) and in patients with or at risk of HIT undergoing percutaneous coronary intervention (PCI; in the USA). HIT is a relatively common extreme prothrombotic condition. When HIT is reasonably suspected, an alternative anticoagulant should be promptly initiated. In historical controlled studies, argatroban reduced new thrombosis, mortality from thrombosis and the composite of death, amputation or thrombosis, without increasing bleeding. With intravenous infusion, advantages include short half-life, easy monitoring and elimination primarily by hepatobiliary (rather than renal) means. In patients undergoing PCI, argatroban with or without glycoprotein IIb/IIIa inhibition leads to high rates of procedural success with low bleeding risk. Herein we review argatroban therapy for HIT and for PCI.     

抗感染药物专业临床药师参与疑难病例治疗的实践体会

目的探索抗感染药物专业临床药师参与疑难病例治疗的工作模式,提高临床药师工作的科学性与可行性。方法结合我院抗感染药物专业临床药师的工作实例,探讨临床药师参与疑难病例治疗的工作模式。结果抗感染药物专业临床药师参与疑难病例的临床治疗团队有利于临床做出更加合理的药物治疗决策。结论临床药师可为临床疑难病例治疗提供优良的药学服务。     

Management of heparin-induced thrombocytopenia

Background: Heparin-induced thrombocytopenia (HIT) is a rare but severe prothrombotic adverse effect of heparin treatment. The underlying cause is the formation of highly immunogenic complexes between negatively charged heparin and positively charged platelet factor 4 (PF4). Resulting antibodies against these PF4/heparin complexes can activate platelets via the platelet FcγIIa receptor, leading to thrombin generation and thus to the paradox of a prothrombotic state despite thrombocytopenia and application of heparin. Prompt diagnosis of HIT is important in order to change treatment to prevent severe thromboembolic complications. However, this is often difficult as thrombocytopenia is frequent in hospitalized patients and the commercially available laboratory tests for HIT antibodies have a high negative predictive value but only a poor positive predictive value. This leads to overdiagnosis and overtreatment of HIT, which also bear the risk for adverse outcomes.

Areas covered: This review aims at resuming recent data on HIT, thereby focusing on the role of new anticoagulants and providing a framework for diagnosis and treatment. Furthermore, it provides some insights into the pathogenesis of this peculiar adverse drug reaction and ventures a guess at its future relevance in clinical practice.

Expert opinion: New drugs which are strongly negatively charged should be assessed for their capacity to form complexes with PF4. If they do so, they bear the risk of inducing a HIT-like immune response. The immunology of HIT is still largely unresolved. Understanding HIT might provide insights into other immune and autoimmune response mechanisms.     

从会诊一例"输液反应"谈药师参与临床用药

目的：通过临床会诊的一个实例介绍药师参与临床用药的体会。方法：药师应邀参与一例关于临床发生的“输液反应”的会诊,对其进行综合分析,找出发生“输液反应”的原因。结果：药师提出的会诊意见和建议被临床医师接受。结论：药师参与临床用药虽前景广阔,但仍需长期不懈努力。