邓青 蒋国君 李艳 边原

摘 要 目的：总结临床药师参与1例低剂量华法林抗凝致国际标准化比值（INR）异常升高患者的临床实践，为患者合理用药提供参考。方法：临床药师通过分析1例低剂量华法林致INR异常升高的原因及影响因素，建议临床医生及时调整用药方案，及进行药学监护（监测出血事件等）。结果：合并用药伏立康唑、头孢哌酮舒巴坦可能是导致INR异常升高的原因，根据患者具体情况予以个体化用药方案。结论：临床药师在治疗团队中应发挥专业特长，参与患者华法林个体化抗凝方案的制订，更好地保障抗凝治疗的有效性和安全性。

关键词 临床药师 华法林 国际标准化比值 伏立康唑 个体化抗凝方案

中图分类号：R973.2； R969.3 文献标志码：C 文章编号：1006-1533（2021）05-0057-03

*基金项目：四川省省级公益性科研院所基本科研业务专项课题（2018YSKY0017）

Clinical pharmacist participated in anticoagulation treatment of a patient with abnormally high INR caused by low-dose warfarin*

DENG Qing1**， JIANG Guojun1， LI Yan1， BIAN Yuan2***

（1. Department of Pharmacy， the Second Affiliated Hospital of Guilin Medical University， Guangxi Guilin 541199， China； 2. Department of Pharmacy， Sichuan Academy of Medical Sciences & Sichuan Provincial Peoples Hospital， Chengdu 610072， China）

ABSTRACT Objective： To summarize the clinical practice of a clinical pharmacist participating in a patient with abnormally high international normalized ratio （INR） caused by low-dose warfarin anticoagulation， so as to provide a reference for the rational use of drugs by patients. Methods： The clinical pharmacist analyzed the causes and influencing factors of an abnormally high INR caused by low-dose warfarin， and recommended timely adjustment of medication regimen and bleeding monitoring and other pharmaceutical monitoring. Results： Drugs such as voriconazole may be the cause of the abnormal increase in INR. Individualized medication regimens should be given according to the specific situation of the patient. Conclusion： Clinical pharmacists should play professional expertise in the treatment team， participate in the formulation of individual anticoagulation schemes of warfarin， comprehensively analyze the factors affecting the anticoagulation effect of warfarin from drug-related factors， and develop pharmacy for clinical and patients services to better guarantee the effectiveness and safety of anticoagulant therapy.

KEY WORDS clinical pharmacist； warfarin； international normalized ratio； voriconazole； personalized anticoagulation regimen

華法林作为临床常用的防治血栓栓塞疾病的口服抗凝药，广泛应用于心脏人工瓣膜置换术后、心房颤动、肺栓塞以及深静脉血栓等抗凝治疗。因华法林治疗窗窄、个体差异大、药物相互作用多，很容易因剂量调整不当或合并用药而导致出血或者栓塞的事件发生，临床使用期间需严密监测国际标准化比值（INR）以指导个体化给药剂量，必要时行基因检测协助抗凝方案制订。现就1例低剂量华法林抗凝致INR异常升高的病例进行分析，探讨其影响因素，为临床治疗提供警示及参考。

1 病例资料

患者，男，46岁，因“反复胸闷、心累2年余，加重伴发热、咯血10 d余”入院。……