一例非瓣膜性房颤合并慢性肾脏病患者的口服抗凝药物治疗的全程药学监护

目的 探讨临床药师在非瓣膜性房颤合并慢性肾脏病患者个体化抗凝治疗中的作用.方法 临床药师参与非瓣膜性房颤合并慢性肾脏病患者的治疗过程,临床药师根据该患者在抗凝治疗过程中出现肾功能及进食状态的改变对使用口服抗凝药物的选择提出建议,并联合医护人员对患者进行药学监护及用药教育.结果 通过实施药学监护及医药护的密切配合,患者病...     

LVAD植入术后患者个体化抗凝治疗的药学实践

目的 ：探讨临床药师在左心室辅助装置植入术后患者个体化抗凝治疗中的作用。方法 ：临床药师全程参与1例左心室辅助装置植入术后患者的抗凝治疗过程，通过多学科会诊、药物基因检测、用药监护等模式提供个体化、精准化药学服务。结果 ：临床药师协助医师制定了术后应用华法林长期抗凝的治疗方案，及时关注到围术期华法林与其他药物间相互作用，动态调整华法林剂量以减少INR大幅波动，避免了出血事件的发生。结论 ：临床药师可积极发挥专业特长协助医师制定和优化患者的治疗方案，保障患者用药安全有效。     

临床药师参与利伐沙班抗凝治疗会诊的案例分析

探讨临床药师在抗凝治疗会诊中协助制定抗凝方案并为患者降低出血风险的作用。选取4例会诊使用利伐沙班的病例，重点分析房颤合并短肠综合征患者、肝硬化合并静脉血栓患者选择利伐沙班抗凝的原因，以及当利伐沙班与其他治疗药物存在相互作用并发生出血时，临床药师主动发现、调整方案并监护的过程，4例患者后期随访中未再发生血栓及出血事件，转归良好。临床药师通过个体化的药学服务为患者在抗凝治疗中平衡血栓与出血的风险，保证患者治疗的安全及有效性。     

临床药师参与抗凝治疗会诊的药学实践与分析

目的 探讨临床药师在抗凝治疗会诊中促进合理用药的作用。方法 选取4例有代表性的疑难少见会诊病例,重点分析利伐沙班在低蛋白血症患者应用的出血风险,使用华法林的妊娠女性抗凝治疗的调整及监护,颅内静脉血栓、左心耳血栓患者使用直接口服抗凝药(DOACs)的决策。结果 临床药师协助临床医生制定个体化抗凝治疗方案并提供药学服务,患者转归良好。结论 临床药师参与抗凝治疗会诊对抗凝药物的合理使用具有重要作用。     

临床药师在缺血性脑卒中精准治疗中的作用

目的分析临床药师如何参与治疗团队,协助医师制定精准化治疗方案。方法以1例达比加群酯抗凝治疗期间发生缺血性脑卒中的病例为例,阐明临床药师如何找准切入点参与药物治疗过程。结果临床药师通过监测药物血药浓度、查阅相关指南及文献综述分析抗凝治疗失败原因并由此提出合理建议,对患者卒中后的抗凝治疗方案进行调整,制订了安全有效的个体化抗凝方案。结论临床药师参与治疗团队,从药学角度出发找准切入点,为患者制订个体化治疗方案,促进临床合理用药。     

1例多种疾病伴随的菌血症患者的药学监护

目的促进临床药师更好地开展药学服务工作。方法通过临床药师对1例伴随多种疾病的菌血症患者的药学监护,关注患者用药方案中抗菌治疗、抗凝治疗、抗菌药物选用,协助医师为患者制订有效、个体化的治疗方案。结果临床药师为患者实施药学监护,可以提高药物治疗效果,减少用药风险。结论临床药师参与临床查房和会诊,对提高临床诊疗水平及保障患者用药安全、有效、经济、合理具有积极作用。     

临床药师对1例慢性肾脏病患者的药学监护

目的为慢性肾脏病患者的药物治疗提供依据。方法临床药师参与1例慢性肾脏病患者的诊疗过程,与临床医师密切配合,为患者制订个体化给药方案,为合理用药提出有益的建议,关注药物不良反应和患者用药教育等方式。结果患者病情稳定,予以出院。结论临床药师深入临床,进行药学服务,有利于提高临床药物的治疗水平。     

长期服用华法林患者围手术期抗凝治疗分析及药学监护

目的 探讨临床药师在长期服用华法林抗凝患者围手术期的药学服务内容和作用。方法 通过对长期服用华法林抗凝患者围手术期出血风险及栓塞风险评估,临床药师帮助临床医师制定规范、合理的个体化抗凝方案,并提出围手术期抗凝治疗的监护重点。结果 通过合理、有效的围手术期抗凝治疗,可在不增加栓塞风险的基础上避免围手术期不良出血事件;同时还可通过药物合理选用及剂量调控,积极有效的规避抗凝药物相关的不良反应。结论 在长期服用华法林抗凝患者的围手术期治疗中,临床药师应根据患者栓塞及手术风险,从术前评估、是否给予桥接治疗、术后抗凝、抗凝药物选择及剂量等方面,为患者提供个体化的抗凝治疗方面。     

临床药师参与1例心房颤动患者抗凝管理的实践与体会

为了探索临床药师参与心房颤动患者治疗及抗凝治疗管理的工作要点和作用,笔者结合典型实例,介绍临床药师开展药学服务及参与抗凝管理工作的体会.确定了个体化的抗凝方案,提高了患者的安全性、依从性以及自我管理能力.临床药师对房颤患者的药学监护降低了血栓和出血的风险,是有效的和必要的.     

1例结肠癌合并静脉血栓病例临床用药分析和药学监护

目的 探讨临床药师在结肠癌合并静脉血栓患者治疗过程中发挥的个体化药学服务作用。方法 临床药师通过临床药学查房、详细的药学问诊、会诊、查阅文献和交流讨论等，参与患者抗凝治疗，抗感染治疗，对低分子肝素（LMWH）在围手术期的使用以及术后出血的原因进行分析，提出处理意见，对患者进行用药教育。结果 对结肠癌合并静脉血栓患者的治疗以及围手术期的处理应该权衡利弊进行个体化管理，同时警惕低分子肝素导致的出血性不良反应。结论 临床药师积极高效参与患者治疗过程，提供个体化药学服务，协助医师制定治疗方案，有利于抗凝药物和抗感染药物的合理、安全使用。     

Review of Challenges in Optimizing Oral Anticoagulation Therapy for Stroke Prevention in Atrial Fibrillation

Oral anticoagulant therapy is the mainstay of stroke prevention in patients with atrial fibrillation; it is highly effective at reducing stroke risk, but its use can be limited by increased risk of bleeding. As new oral anticoagulants are available, barriers to optimal use of oral anticoagulation therapy warrant consideration by healthcare professionals and administrators who are seeking to optimize the quality of care for patients with atrial fibrillation. Suboptimal use of oral anticoagulation therapy constitutes an important health problem with significant humanistic and economic consequences. Based on a review of the medical literature published between 2000 and 2011, this article summarizes the literature on the barriers to optimal use of oral anticoagulation therapy, describes the clinical and economic burdens that these barriers add to the burden of atrial fibrillation, and discusses how well the new oral anticoagulants may address some of these issues.     

心房颤动患者左心耳封堵术后抗栓策略

心房颤动可引起血栓栓塞,甚至脑卒中.大多数房颤患者血栓主要形成于左心耳.左心耳封堵术(LAAO)通过对左心耳进行介入封堵,以替代长期口服抗凝药预防血栓栓塞,其安全性和有效性已在众多临床研究中得到证实.LAAO后抗栓治疗对患者的康复及减少不良反应的发生至关重要.目前LAAO后抗栓治疗策略主要有抗凝+抗血小板联合治疗、双联...     

Incorporating Comprehensive Management of Direct Oral Anticoagulants into Anticoagulation Clinics

Anticoagulation clinics emerged as a means to optimize warfarin effectiveness and minimize bleeding risks. Anticoagulation clinics have traditionally been warfarin‐based models due to the need for frequent blood‐level monitoring, drug interactions, dietary considerations, and periprocedural management with warfarin. These models have demonstrated improved anticoagulation control and reduced bleeding complications for patients taking warfarin. Direct oral anticoagulants (DOACs) emerged with the perception of improved convenience due to the lack of blood‐level monitoring and lack of dietary considerations. Despite the advantages of DOAC therapy, new challenges exist with their management, warranting ongoing monitoring. Such challenges include prescribing and dosing issues, drug adherence, drug interactions, and high drug cost. Comprehensive anticoagulation centers are needed to manage and monitor all oral anticoagulants including DOACs. The objectives of this review are to describe the challenges and opportunities that exist in the management of DOACs and to describe a practice model that integrates a DOAC management service into the traditional anticoagulation clinic.     

Anticoagulation patient self-monitoring in the United States: considerations for clinical practice adoption

Systematic management models such as anticoagulation clinics have emerged in order to optimize warfarin effectiveness and to minimize related complications. Most of these models are structured so that patients come to a clinic for in-person testing and evaluation, thus making this model of care difficult to access and time consuming for many patients. The emergence of portable instruments for measuring anticoagulant effect in capillary whole blood made it possible for patients receiving warfarin to self-monitor the effect of their anticoagulant therapy. Self-monitoring empowers patients, offers the advantage of more frequent monitoring, and increases patient convenience by allowing testing at home and avoiding the need for frequent laboratory and clinic visits. Self-monitoring can entail patient self-testing (PST) and/or patient self-management (PSM). Several studies have evaluated and shown the benefit of both PST and PSM models of care when compared with either routine medical care or anticoagulation clinic management of anticoagulation therapy. Self-monitoring (PSM and/or PST) of anticoagulation results in lower thromboembolic events, lower mortality, and no increase in major bleeding when compared with standard care. Despite favorable results and enhanced patient convenience, the adoption of self-monitoring into clinical practice in the United States has been limited, especially in higher risk, disadvantaged populations. Although the emergence of a multitude of novel oral anticoagulants will permit clinicians to better individualize anticoagulant therapy options by choosing the optimum regimen based on individual patient characteristics, it is also expected that traditional agents will continue to play a role in a significant subset of patients. For those patients treated with traditional anticoagulants such as warfarin, future models of care will entail patient-centered management such as PST and PSM. The incorporation of technology (i.e., Web-based expert systems) is expected to further improve the outcomes realized by PST and PSM. Further studies are needed to explore factors that influence the adoption of self-monitoring in the United States and to evaluate the feasibility and implementation in real-life clinical settings.     

新型口服抗凝药在非瓣膜性房颤合并脑血管病中的研究进展

抗凝治疗被认为是非瓣膜性心房颤动(房颤)患者缺血性卒中预防策略的基石。新型口服抗凝药相较于传统口服抗凝药华法林, 具有起效快、半衰期短、药物相互作用少以及无需频繁监测凝血指标等优点, 被普遍应用于预防治疗中, 大幅降低了非瓣膜性房颤患者缺血性卒中的发生风险。但对于合并颅内动脉粥样硬化狭窄、急性缺血性卒中、颅内出血、颅内微出血等增加卒中及出血风险的非瓣膜性房颤患者, 临床抗凝治疗及启动时间的选择无疑是个挑战。本文将对新型口服抗凝药在合并常见脑血管病的非瓣膜性房颤患者中的应用进行综述, 为临床治疗与预防提供参考。     

Evaluation and management of atrial fibrillation

Atrial fibrillation (AF) is the most common clinically encountered arrhythmia affecting 0.4% of the general population. Its prevalence increases with age, affecting more than 6% of people over 80 years of age. The annual risk of ischemic stroke in patients with lone AF is approximately 1.3%. This annual risk increases up to 10% -12% in patients with a prior stroke or transient ischemic attack. Randomized clinical trials (RCT) comparing adjusted-dose oral anticoagulation and placebo showed a risk reduction of 61% (95% CI 47% to 71%). The absolute risk reduction for stroke with oral anticoagulants is about 3% per year. Aspirin has been shown in meta-analyses to have on average a 20-25% relative risk reduction, and is inferior to oral anticoagulants. In high risk patients with AF warfarin is a class I ACC/AHA indication unless there is a contraindication for anticoagulation. Unfortunately, this therapy requires frequent monitoring with blood samples and the interaction with food and several medications makes its use difficult and sometimes unreliable. It requires strict patient compliance and its use is also linked to potentially serious bleeding complications. In clinical practice, less than 60% of patients who do not have contraindications to oral anticoagulation are actually receiving them. Additionally, of those that receive oral anticoagulation, less than 50% are consistently within therapeutic targets. As such, the "real world" efficacy of a strategy towards prescribing oral anticoagulants is likely significantly lower than that demonstrated in clinical trials. As such, the need to discover other methods of anticoagulation with oral bioavailability, predictable pharmacokinetics, and minimal interactions with diet and other pharmacological agents is imperative. Low molecular weight heparin has a more predictable bioavailability and a longer half-life, but its subcutaneous mode of administration and long-term risks, in particular, osteoporosis makes the chronic use of this medication non-feasible. Antiplatelet agents such as clopidogrel have proven efficacy and superiority compared to aspirin to prevent systemic vascular events in at-risk patient populations, but currently they do not play an important role in the prevention of AF related thromboembolic events. The ACTIVE study is a randomized trial comparing the combination of clopidogrel and aspirin therapy to oral anticoagulation with warfarin in patients with AF, and was unfortunately terminated prematurely by the data safety and monitoring board because of increased events in the antiplatelet arm. Direct thrombin inhibitors, such as ximelagatran, may be as effective as warfarin for stroke-risk reduction in patients with AF. No anticoagulation monitoring is needed and it has excellent bioavailability, with a twice-daily oral dose. Elevation of liver enzymes was an initial concern regarding the use of this new drug, which is not available for general use. Ongoing pharmacological research and future clinical trials may one day leave the "warfarin days" behind. Unfortunately, the new therapies that are being tested seem to be at least several years away from being available on a widespread basis. In this review, we discuss the underlying pathophysiology of AF and stroke. We also provide a comprehensive discussion regarding various available therapies to treat AF.     

Physicians’ views on patient participation in choice of oral anticoagulants in atrial fibrillation—a qualitative study

Direct oral anticoagulants provide an alternative to vitamin K antagonists for the anticoagulation therapy in atrial fibrillation (AF). The availability of several treatment options with different attributes makes shared decision‐making appropriate for the choice of anticoagulation therapy. The aim of this study was to understand how physicians choose an oral anticoagulant (OAC) for patients with AF and how physicians view patients’ participation in this decision. Semi‐structured interviews with 17 Finnish physicians (eight general practitioners and nine specialists) working in the public sector were conducted. An interview guide on experience, prescribing and opinions about oral anticoagulants was developed based on previous literature. The data were thematically analysed using deductive and inductive approaches. Based on the interviews, patient's opinion was the most influential factor in decision‐making when there were no clinical factors limiting the choice between OACs. Of patient's preferences, the most important was the attitude towards co‐payments of OACs. Patients’ opinions on monitoring of treatment, dosing and antidote availability were also mentioned by the interviewees. The choice of an OAC in AF was patient‐centred as all interviewees expressed that patient's opinion affects the choice.     

Study on Impact of Clinical Pharmacist’s Interventions in the Optimal Use of Oral Anticoagulants in Stroke Patients

Anticoagulants are very useful medications but can also lead to haemorrhagic as well as thromboembolic complications when not used correctly or without proper medical attention. Anticoagulant’s complex pharmacology and pharmacokinetics contribute to its narrow margin of safety. Pharmacist’s unique knowledge of pharmacology, pharmacokinetics and interactions makes them well-suited to assist patients in maintaining safe and effective anticoagulation. Successful anticoagulation therapy implies fewer incidences of therapeutic failures and bleeding complications. The anticoagulation management service staffed by clinical pharmacists is a service established to monitor and manage oral and parenteral anticoagulants. In this research work, 40 patients each were included in the intervention and the control groups. In the intervention group, patient’s knowledge score on anticoagulation increased from an average of 5.6±3.2 to 13.8±0.94 (P=0.000) after clinical pharmacist’s counselling, whereas in the control group there was no significant improvement in patient’s baseline knowledge over the knowledge score at the end of the study (8.0±1.59 vs. 8.3±2.6) (P=0.218). In the intervention group, 73.45% of the international normalised ratio test results were within the therapeutic range, 8.45% supratherapeutic and 18.5% subtherapeutic during the 6 months data collection period. The corresponding data for the control group were 53.2 (P=0.000), 18.4 (P=0.000) and 28.4% (P=0.002), respectively. Forty four adverse drug reactions (ADRs) related to anticoagulants were identified in the intervention group as compared to 56 in the control group. These results revealed that the clinical pharmacist’s involvement in the anticoagulation management improved the therapeutic outcome of patients and demonstrate the benefits of clinical pharmacist guided anticoagulation clinics in India.     

Patient Self-Monitoring of Oral Anticoagulant Therapy

Coumarin derivatives are widely used oral anticoagulants for patients with chronic atrial fibrillation, venous thromboembolism, valvular heart disease, myocardial infarction or a mechanical prosthetic heart valve. Because of the narrow therapeutic window associated with coumarins and the potential for drug interactions, frequent monitoring of anticoagulation is required to maintain the International Normalized Ratio (INR) between 2.0 to 3.5 for most clinical indications. Monitoring of oral anticoagulant therapy is placing a considerable burden on healthcare providers because many patients require life-long treatment with coumarins, and because of an increasing number of elderly patients with conditions that are treated with coumarins. A novel approach that might, in part, address this healthcare need is patient self-monitoring of anticoagulation with a portable coagulometer. Several cohort studies and randomized controlled trials have found that anticoagulation self-monitoring is as good as, or better than, conventional monitoring in a specialized anticoagulation clinic or by a general practitioner. The advantages of anticoagulation self-monitoring include reduced patient inconvenience relating to anticoagulation clinic visits and laboratory monitoring of warfarin therapy, and fewer INR levels outside the therapeutic INR range if INR measurements are preformed more frequently with anticoagulation self-monitoring. Thus, anticoagulation self-monitoring has the potential to reduce the incidence of thromboembolic and bleeding episodes in patients who are receiving long term oral anticoagulant therapy. The potential drawbacks of anticoagulation self-monitoring include the costs of the portable coagulometer. Additionally, self-monitoring is limited to patients who have the cognitive and physical capabilities to perform the technique required for the portable coagulometer.