临床药师参与1例EGFR阳性非小细胞肺癌合并肾功能不全患者治疗方案调整的药学实践

Clinical pharmacists participated in the pharmaceutical practice of adjusting drug therapy regimen for a patient with EGFR-positive non-small cell lung cancer complicated with renal dysfunction

关键词:  表皮生长因子受体  非小细胞肺癌  肾功能不全  药物相互作用  药学实践

Key words:  epidermal growth factor receptor  non-small cell lung cancer  renal insufficiency  drug interactions  pharmacy practice

摘要:

目的 探讨表皮生长因子受体（EGFR）阳性非小细胞肺癌合并肾功能不全患者的药物治疗调整思路。方法 临床药师通过全程参与1例EGFR阳性非小细胞肺癌合并肾功能不全患者的治疗方案调整，从治疗方案的制定和优化、药物相互作用的潜在风险评估及肾功能不全的原因甄别等方面分析药物治疗调整策略，并协助医师制定个体化的药物治疗方案。结果 对于肿瘤负荷重的EGFR阳性非小细胞肺癌患者，可选择靶向联合化疗治疗模式，并根据其药动学特点及患者肾功能水平采取减量方案；临床药师协助医师分析肾功能不全发生的可能原因，个体化评估药物相互作用的潜在风险，停用或替换非甾体抗炎药、质子泵抑制剂及双膦酸盐类等可疑药物，预防与延缓了肾毒性发生风险；医师采纳药师建议，患者治疗过程顺利，疗效评价为部分缓解。结论 临床药师发挥专业优势，以肾功能不全药学监护作为切入点，在药物合理选用、剂量调整、相互作用及不良反应等方面协助医师调整用药方案，有助于提高肿瘤合并肾功能不全患者的用药安全性和有效性。

Abstract:

OBJECTIVE To explore the adjustment strategies for drug therapy in patients with epidermal growth factor receptor (EGFR) positive non-small cell lung cancer complicated by renal insufficiency. METHODS Clinical pharmacists participated in the adjustment of the treatment plan for a patient with EGFR-positive non-small cell lung cancer complicated by renal insufficiency. The drug therapy adjustment strategy was analyzed from various aspects, including the formulation and optimization of the treatment plan, assessment of potential risks from drug interactions, and identification of the causes of renal insufficiency. The pharmacists assisted physicians in formulating an individualized drug therapy plan. RESULTS For patients with EGFR-positive non-small cell lung cancer with a heavy tumor burden, a targeted combination chemotherapy regimen was selected, and a dose reduction plan was implemented based on pharmacokinetic characteristics and the patient's renal function. Clinical pharmacists assisted physicians in analyzing potential causes of renal insufficiency and assessing the risks of drug interactions. Suspected drugs, including NSAIDs, proton pump inhibitors, and bisphosphonates, were discontinued or replaced to prevent and delay the risk of renal toxicity. The physician adopted the pharmacist's recommendations, resulting in a smooth treatment process, and the patient's response was evaluated as partial remission. CONCLUSION Clinical pharmacists utilized their professional expertise, focusing on pharmaceutical care for renal insufficiency as a starting point. They assisted physicians in adjusting medication regimens by ensuring rational drug selection, dose adjustment, management of interactions, and adverse reactions. This approach helps to improve the safety and effectiveness of drug therapy in patients with tumors complicated by renal insufficiency.