基于临床治疗指南及共识的使用华法林住院患者用药分析与评价

目的：对某院使用华法林的住院患者进行用药分析和评价，并对其出院后复诊情况进行追踪，以更好地发挥华法林的治疗作用，减少不良反应的发生。方法：采用回顾性的分析方法，对某院2018年7月-12月使用华法林的住院患者用药进行分析，结合指南、共识对其用药情况进行分析评价。结果：共调取509份病例，华法林的使用主要分布于心血管内科、心血管外科、呼吸内科。华法林应用临床诊断主要为肺栓塞、心房颤动、肺动脉高压、静脉血栓等；住院患者华法林用量范围为0.625~9 mg，平均日剂量（2.99±1.11）mg；全院服用华法林后INR总体测定率为79%，将INR值以"<2.0"、"2.0~3.0"、">3.0"分布进行统计，INR2.0~3.0占比为33.17%，最高的为呼吸内科。26例（5.11%）患者住院期间INR达到4.5~10.0，38.46%使用维生素K进行拮抗；2例（0.39%）患者INR大于10，全部使用维生素K进行拮抗。在院期间合用其他抗凝药中，低分子肝素使用率最高的为骨外科，心血管外科，心血管内科；普通肝素使用率最高的为呼吸内科；阿加曲班使用率最高的为神经内科；利伐沙班使用率最高的为心血管内科，根据相关指南共识分析用药基本合理。患者出院后一周内及总复诊率最高的均为呼吸内科。复诊后INR分布在2.0~3.0占比最高的也为呼吸内科，与呼吸科临床药师药学监护及用药教育相关。结论：目前华法林临床应用仍不够规范，INR达标率偏低，出院后复诊率较低，抗凝药物转换过程中有不规范的问题，积极开展药师药学监护、用药教育及随访具有重要意义。

Analysis and evaluation of hospitalized patients with application of Warfarin on the basis of guidelines and consensuses

OBJECTIVE To analyze and evaluate the use of Warfarin in hospitalized patients in a hospital, and to track their return visits after discharge in order to enhance the therapeutic role of warfarin and reduce the occurrence of adverse reactions. METHODS A retrospective analysis method was used to analyze the use of Warfarin in inpatients from July to December 2018 in a hospital, and the use of Warfarin was analyzed and evaluated in combination with guidelines and consensus. RESULTS A total of 509 cases were collected. Warfarin was mainly used in cardiology department, cardiovascular surgery department and respiratory department. Warfarin was mainly used for patients with pulmonary embolism, auricular fibrillation, pulmonary arterial hypertensionand deep vein thrombosis in our hospital. The dosage of Warfarin was in the range of 0.625-9 mg with average daily dosage of(2.99±1.11)mg. After administration of Warfarin in the hospital, the overall INR measurement rate was 79%. According to the distribution of INR values as "<2.0", "2.0-3.0" and ">3.0", the proportion of INR 2.0-3.0 was 33.17%, and the highest was in respiratory department. There were a few other anticoagulant used with the Warfarin. The low molecular heparin was mostly used in the department of orthopaedics. The heparin was mostly used in respiratory department. The argatroban was mostly used in neurology department. The rivaroxaban was mostly used in cardiology department.CONCLUSION At present, the clinical application of warfarin is still not standardized, and both of the INR compliance rate and the return visit rate after discharge remain low, and there are problems in the process of anticoagulant switching. It is of great significance to actively carry out pharmacist pharmaceutical care, medication education and follow-up.