例多种心血管疾病合并类风湿关节炎患者的药学监护

1 例77 岁女性患者,因反复胸闷、心悸15 年,加重1 个月入院.入院诊断为冠状动脉粥样硬化性心脏病,急性冠脉综合征,阵发性心房颤动;高血压3 级（很高危）,高血压性心脏病;类风湿关节炎;胃窦溃疡.入院给予抗炎、抗血小板、调节血脂、止痛、房颤转复、降血压、保护胃黏膜等治疗.患者长期应用糖皮质激素会导致血糖代谢紊乱、胃黏膜损伤、骨质疏松等症状,对甲泼尼龙片、盐酸胺碘酮、他汀类药物不良反应进行监测,考虑到埃索美拉唑可能与氯吡格雷存在代谢酶竞争,从而导致氯吡格雷抗栓效果不充分,临床药师建议将埃索美拉唑调整为泮托拉唑.同时,对患者进行用药教育,保障患者用药安全、有效.

Pharmaceutical care on a patient with rheumatoid arthritis combined with multiple cardiovasculardiseases

One 77-year-old female patient with chest tightness and palpitations for 15 years, aggravation for one monthwas hospitalized. The patient was diagnosed as coronary heart disease, acute coronary syndrome, paroxysmal atrial fibrillation,hypertension, hypertensive heart disease, rheumatoid arthritis and antral ulcer. The patient received anti-inflammatory, antiplatelet,regulating blood lipid, relieving pain, cardioversion of atrial fibrillation, reducing blood pressure, protection of gastric mucosatherapy. Clinical pharmacist paid close attention to disorder of glucose metabolism, gastric mucosal injury, osteoporosis caused bylong term use of corticosteroids, monitored the potential adverse drug reactions caused by methylprednisolone, amiodarone andstatins. Considering the competition of metabolic enzyme CYP2C19 between esomeprazole and clopidogrel which may lead toinadequate antithrombotic effect of clopidogrel, clinical pharmacist suggested that esomeprazole should be replaced by pantoprazole.Clinical pharmacists provided education on the medication for the patient and played an important role in the safety as well aseffectiveness of drug use.