对1例腹膜透析发生腹膜炎患者的药学服务

［摘要］目的：通过临床药师对1例腹膜透析发生腹膜炎患者的1次完整的个体化给药方案的设计和实施,说明药师在临床住院患者治疗中发挥的作用。方法：针对临床具体病例,临床药师通过运用所学知识和经验,查找多方循证医学证据,为患者提供针对病情的个体化给药方案并具体实施,观察药物治疗效果。结果：临床药师为患者提供药学服务可以提高患者治疗的依从性,减少用药风险,提高患者生活质量。结论：临床药师为患者提供个体化全程药学服务,可以为医、患双方提供安全、高效的用药方案。以临床药师为主体的药学服务得到了一定的效果。     

儿科临床药师在治疗药物监测中的作用

治疗药物监测(Therapeutic Drug Monitoring,TDM)是近30年来形成的一门临床医学分支学科,也是临床药理学研究的重要内容之一.其通过运用各种灵敏的现代分析测定手段,定量分析生物样品(特别是患者用药后血浆或其它体液)中药物或其代谢产物的浓度.     

Problems in therapeutic drug monitoring: free drug level monitoring

Historically, it has been assumed that only free drug concentration is the pharmacologically active species. This article reviews the theoretical pharmacological and pharmacokinetic justifications for monitoring free drug levels. The determinants likely to influence plasma protein binding and the free concentrations of drugs are delineated. The different methods which can be used for determining free drug level are presented. Their advantages and drawbacks as well as their reliability and suitability for routine clinical practice are discussed. Currently, antiepileptic drugs such as valproic acid, phenytoin, carbamazepine and a few antiarrhythmic drugs meet the theoretical criteria justifying free drug level monitoring. Conditions causing alteration in free concentrations of these drugs are reported. But, for all these drugs, there is a considerable lack of data establishing the correlations between therapeutic or toxic response and free concentration. Presently, our capability to interpret correctly the free drug level data is still limited. In the future, much more effort must be devoted in order to provide sufficient information on the clinical relevance of free drug concentration.     

对1例腹膜透析患者的药学监护

1例67岁男性患者,因冠心病、急性冠脉综合征入院治疗,入院时合并有风湿性心脏病、慢性肾功能不全尿毒症期（双侧肾脏萎缩）等多种疾病,给予扩冠、降脂、抗血小板、抗凝等治疗,并于入院后第2天行经皮冠状动脉介入治疗,术后患者出现急性左心衰合并肺部感染,给予利尿、强心、化痰、平喘、抗感染等药物治疗。针对患者需要腹膜透析的情况临床药师建议进行强心药物地高辛的血药浓度监测,规避地高辛蓄积中毒的风险。在抗感染治疗中,根据痰培养结果,结合腹膜透析可部分清除氟康唑的特点,建议在透析后给予氟康唑,并给予不受腹膜透析影响的左氧氟沙星进行抗感染治疗,同时对抗感染治疗过程中使用的亚胺培南西司他丁以及左氧氟沙星引起的震颤、失眠等不良反应进行监测。     

Immunophilins: their properties and their potential role in therapeutic drug monitoring

This article reviews recent developments in the immunophilin arena and the current state of knowledge about the biochemical properties of immunophilins. The role of immunophilin-binding assays is also explored with the conclusion that some of these immunosuppressive-drug-binding proteins may provide better assays for sirolimus and tacrolimus than current immunoassays.     

Cost-effectiveness of therapeutic drug monitoring: a systematic review

There are a number of effective but highly toxic drugs that exhibit a narrow therapeutic index and marked interpatient pharmacokinetic variability. Individualized therapy with such drugs requires therapeutic drug monitoring (TDM) to obtain the desired clinical effects safely. Cost-effectiveness analysis in health care is still at an early stage of development, especially for TDM. A systematic review was carried out to document studies that have addressed the cost-effectiveness of TDM. The Cochrane database and Medline were searched. References identified by this approach were then searched manually for relevant articles. Very few studies have been performed that document the cost-effectiveness of TDM, and TDM has been demonstrated to be cost-effective only for aminoglycosides. For the other classes of drugs that are monitored, the rationale for TDM has been supported, but appropriate cost-effectiveness analyses have not been performed. Because the use of many of these drugs without TDM would increase the risk of under- or overdosing, emphasis should not be placed solely on cost-effectiveness but rather on how such interventions can be applied in the most cost-effective and clinically useful manner.     

Use of peritoneal dialysis as a therapeutic method in poisoning by Neguvon

In experiments on female rats the effect of peritoneal dialysis with variously diluted human plasma in peroral poisoning with the organophosphorous insecticide Neguvon, in which inhibition of blood acetylcholinesterase occurs, was examined. Out of the three protein plasma concentrations tested (7 g/l, 70 g/l and 140 g/l), the highest increase in the activity of the inhibited acetylcholinesterase in the blood was induced with the concentration of 70 g/l. A closer examination of the effect of the individual components of the dialysate for Neguvon poisoning revealed that approximately 60% of the effect of treatment is due to albumin, 40% to butyrylcholinesterase in the administered plasma. The comparison of the inhibition of butyrylcholinesterase in the plasma, which was administered as the dialysate, with Neguvon in vitro and in vivo shows that the inhibition of butyrylcholinesterase in the dialysate in vivo is produced by about 35% of the Neguvon dose, administered to experimental animals, and that therefore the actual dose of Neguvon, which induced the poisoning, was decreased to two thirds. This is in agreement with the fact that the LD50 value in treated rats after single-dose administration of the dialysate is more than two times higher than in untreated rats.     

Central nervous system toxicity of tricyclic antidepressants: phenomenology, course, risk factors, and role of therapeutic drug monitoring

Central nervous system (CNS) toxicity of tricyclic antidepressants (TCAs) is serious, costly, frequent, and difficult to diagnose early in its course. We first reviewed all published, systematic population studies of such CNS toxicity. Of 976 TCA-treated patients, 58 (6%) developed TCA-induced CNS toxicity. The risk of this toxicity was positively correlated with TCA plasma levels. For levels greater than 450 ng/ml, the risk increased more than 10-fold (to 67%). We further analyzed 36 cases in terms of phenomenology, course, and potential risk factors of TCA-induced toxicity. A protean prodrome involving affective, psychotic, and cognitive symptoms preceded the delirium, which on average took 2 weeks to develop. The variability of this prodrome often leads to erroneous clinical decisions. Risk factors for delirium, in order of importance, included TCA concentration in plasma, age, and female gender.     

Posaconazole: the case for therapeutic drug monitoring

Invasive fungal infections are associated with high morbidity and mortality. Antifungal therapeutic options remain relatively limited; therefore, optimization of present regimens is essential. Posaconazole is licensed for prevention of invasive fungal infections and oropharyngeal candidiasis and salvage therapy for invasive aspergillosis. Recent data suggest that therapeutic drug monitoring may be an important tool for patient management. Clinical and laboratory animal data suggest that posaconazole demonstrates clinically relevant exposure-response relationships. Higher systemic drug exposure is associated with improved clinical outcomes. Potentially subtherapeutic concentrations are frequently encountered in critically ill patients. Therapeutic drug monitoring provides a way to optimize the use of posaconazole, and this review summarizes the indications and process by which this can be achieved.     

万古霉素致腹膜透析患者全血细胞减少的用药分析与不良反应监护

目的 为临床药师参与腹膜透析相关性腹膜炎患者的抗感染治疗和个体化药学服务实践提供参考.方法 临床药师通过对1例腹膜透析患者万古霉素血药谷浓度的监测,根据腹透液细菌培养与药敏结果评价以调整抗感染治疗方案,并对万古霉素所致的全血细胞减少进行了不良反应监护.结果 有效控制了该腹膜透析患者的感染,全血细胞减少的相关指标有所好转...     

Economic impact of aminoglycoside toxicity and its prevention through therapeutic drug monitoring.

Therapeutic drug monitoring (TDM) of aminoglycoside antibacterials with the goal of minimising toxicity and maximising effectiveness has become routine. Successful management of serious infections requires the ability to achieve therapeutic peak concentrations, while maintaining low trough concentrations will assist in avoiding nephrotoxicity. Reported nephrotoxicity rates range from 1.7 to 58% and depend on the definition used, the patient group studied, concomitant drug therapy used and whether TDM services have been provided. TDM services have been shown to reduce aminoglycoside nephrotoxicity. The costs of providing TDM averages $US301.87 (1997 values) per patient and the cost for each use of nephrotoxicity is estimated at $US4583 (1997 values). In order for the costs of providing a TDM service to 100 patients ($US30,187) to be offset by cost savings due to decreasing nephrotoxicity, the service would need to be able to reduce nephrotoxicity by 6.6%, resulting in a saving of $US30,248. The ability to achieve this saving is dependent on the characteristics of the population in which aminoglycoside therapy is used. In populations where high rates of nephrotoxicity (e.g. > 15%) would be expected, TDM services are cost justified. In populations where nephrotoxicity is low (e.g. < 5%), TDM service is not justified for this purpose. In order to provide a cost-efficient approach to TDM, resources should be focused on providing service to high risk patient groups.     

Cost-effectiveness of therapeutic drug monitoring

Cost effectiveness analysis (CEA) has been applied to a wide range of health care procedures including TDM. The need for CEA of TDM has resulted from economic pressures for cost justification exerted by hospital administrators, government and, in the United States, by third party health insurers. The lack of well-designed studies has made it difficult to prove (or disprove) the credibility of TDM on an economic basis. When conducting a cost analysis evaluation of TDM, all costs and benefits must be identified, and to determine the program's viability, a study-specific analytical model is required. Ideally, the study should be controlled, comparative, prospective and have patient outcome as an assessed endpoint. Therapeutic drug monitoring has been shown to be cost-effective when SDCs are used with a sound pharmacokinetic basis, when the drugs monitored show a strong correlation between serum concentration and therapeutic outcome, and when the program has been well accepted by the professional personnel within the institution.