儿童急性缺血性脑卒中抗血小板治疗的个性化方案与药学实践研究

Personalized Antiplatelet Therapy and Pharmaceutical Care in Pediatric Acute Ischemic Stroke: A Clinical Study

关键词:  儿童  急性缺血性脑卒中  阿司匹林  氯吡格雷  布洛芬  肥胖

Key words:  pediatric  ischemic stroke aspirin  clopidogrel  ibuprofen  obesity

摘要:

目的：探讨儿童急性缺血性脑卒中患者的抗血小板个性化治疗方案及药学监护要点，为临床安全用药提供参考。方法：对1例12岁左侧颈内动脉近段重度狭窄-闭塞患儿的诊疗过程实施全程化药学监护。药师系统检索文献，并根据患儿个体情况协助医生设计抗血小板药物给药方案，监护出血等不良反应。结果：该患儿左侧颈内动脉近段重度狭窄-闭塞，该类型卒中在儿童中较为罕见，且该患儿年满12岁，体重也达到了成人体重，因而参考成人选择了双联抗血小板治疗方案，同时患儿存在肥胖（BMI = 29.2），可能会降低抗血小板治疗反应性。患儿住院过程中因腰背穿刺后疼痛，多次使用布洛芬，可导致阿司匹林抗血小板效果降低，而出血风险增加。医生采纳了药师提供的阿司匹林肠溶片100mg po qd 和氯吡格雷片75mg po qd双抗治疗方案建议，同时停用了布洛芬止痛，改用地塞米松注射液5mg静滴。患儿治疗后第4天右侧握力较前好转，肢体活动自如，第7天患儿出现鼻腔出血（Ⅰ 级），但自行按压后可止血，总体治疗有效性和安全性良好。结论：儿童急性缺血性脑卒中抗血小板治疗需建立个性化方案，目前阿司匹林和氯吡格雷双联抗血小板治疗儿童急性缺血性脑卒中的循证证据有限，本案例为儿童双联抗血小板治疗的疗效-风险平衡提供了新的证据，但仍需要进一步开展高水平多中心儿童临床试验研究来验证该方案的有效性和安全性。

Abstract:

OBJECTIVE To explore personalized antiplatelet regimens and key pharmaceutical care considerations for pediatric acute ischemic stroke (AIS), providing evidence for clinical medication safety. METHODS Comprehensive pharmaceutical care was implemented for a 12-year-old child with severe stenosis-occlusion of the proximal left internal carotid artery. Dual antiplatelet therapy (DAPT) combining aspirin (100 mg/day) and clopidogrel (75 mg/day) was initiated. A systematic literature review analyzed the uniqueness of pediatric antiplatelet therapy. RESULTS The child was diagnosed with severe stenosis to occlusion of the proximal left internal carotid artery. This type of stroke is relatively rare in children. Since the child is already 12 years old and has reached an adult weight, a dual antiplatelet therapy regimen was selected with reference to adult treatment guidelines. Additionally, the pediatric patient presented with obesity (BMI = 29.2), which may reduce responsiveness to antiplatelet therapy. During hospitalization, the patient received ibuprofen multiple times for post-lumbar puncture back pain. This use of ibuprofen could potentially reduce the antiplatelet efficacy of aspirin while increasing the bleeding risk. The physician adopted the pharmacist's recommended DAPT regimen of Aspirin Enteric-Coated Tablets 100 mg orally once daily and Clopidogrel Tablets 75 mg orally once daily. Concurrently, ibuprofen was discontinued for analgesia and replaced with Dexamethasone Injection 5 mg administered via intravenous drip. By day 4 of treatment, the patient's right-hand grip strength had improved compared to baseline, and limb mobility was unrestricted. On day 7, the patient experienced Grade I epistaxis (nasal bleeding), which was controlled with manual compression. Overall, the treatment demonstrated favorable effectiveness and safety. CONCLUSION Pediatric AIS requires personalized antiplatelet regimens. Currently, there is limited evidence-based evidence for the use of dual antiplatelet therapy with aspirin and clopidogrel in the treatment of acute ischemic stroke in children, Our case provides new evidence regarding the benefit-risk balance of dual antiplatelet therapy, underscoring the need for further high-level multicenter clinical trials in children to validate the effectiveness and safety of this regimen.