临床药师对30例布氏菌性脊柱炎患者的药学监护

目的：探讨临床药师对布氏菌性脊柱炎患者的药学监护内容，为临床药师的药学实践提供参考。方法：临床药师以2017年5月-2017年12月某院骨科收治的30例布氏菌性脊柱炎患者为研究对象，采取跟踪服务方法，参与药物治疗方案的制定，对患者进行用药教育、监护围手术期药物不良反应（ADR）和相互作用（DDI）。结果：30例患者中男性25例，女性5例，年龄25~69岁，平均（53.63±10.39）岁；入院前病程20 d~14个月，病程中位时间为3个月；17例患者有明确的牛羊接触史；临床药师发现药物不良反应（ADR）17人次（肠道菌群失调8人次，药物性肝损伤8人次，左氧氟沙星导致精神异常1人次），药物相互作用（DDI）31人次（利福平与奥美拉唑14人次，利福平与氟康唑6人次，利福平与硝苯地平2人次，利福平与酒石酸美托洛尔2人次，利福平与利伐沙班1人次，利福平与多西环素1人次，多西环素与琥珀酸亚铁3人次，多西环素与铝镁加混悬液1人次，多西环素与卡马西平1人次），并提出停药和/或合理的治疗方案。结论：临床药师深入临床，以患者为中心，以健康宣教、用药教育、ADR和DDI为切入点，开展个体化药学服务，确保用药安全。

Pharmaceutical care for 30 patients with Brucella spondylitis provided by clinical pharmacist

OBJECTIVE To provide references for clinical pharmacists by discussing the pharmaceutical care for patients with Brucella spondylitis.METHODS The subjects of the study were 30 patients with Brucella spondylitis admitted to a hospital from May 2017 to December 2017. The clinical pharmacist carried out a series of tracking pharmaceutical care including:participating in the therapeutic schedule confirming, monitoring the possible adverse drug reactions (ADRs) and drug-drug interactions (DDIs) closely, and conducting medication education.RESULTS There were 30 cases including 25 males and 5 females, aged from 25 to 69 years old, with an average age of (53.63±10.39) years. The duration of the disease was 20 days to 14 months before admission, with a median of 3 (2,5) months. There were 17 cases with a history of contacting with cows or sheep. The clinical pharmacist found 17 ADRs (8 cases of intestinal flora imbalance, 8 of drug-induced liver injury, and 1 Levofloxacin led to mental abnormalities) and 31 drug interactions (14 by rifampicin and omeprazole, 6 by rifampicin and fluconazole, 2 by rifampicin and nifedipine, 2 by rifampicin and metoprolol, 1 by rifampicin and rivaroxaban, 1 by rifampin and doxycyclin, 3 by doxycyclin and ferrous succinate, 1 by doxycyclin and aluminum magnesium mixed suspension, 1 by doxycyclin and carbamazepine), and proposed to discontinue drugs and/or adopt other therapy.CONCLUSION The clinical pharmacists take the health education, medication education, ADR and DDI as breakthrough points, going into the inpatient wards and providing the individualized pharmaceutical care to ensure the safety.