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Article(id=1195009885118120517, tenantId=1146029695717560320, journalId=1190317699101192196, issueId=1195009883369091469, articleNumber=1001-2494(2025)09-1000-05, orderNo=null, doi=10.11669/cpj.2025.09.013, pmid=null, cstr=null, oa=null, hot=1, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1735574400000, receivedDateStr=2024-12-31, revisedDate=null, revisedDateStr=null, acceptedDate=null, acceptedDateStr=null, onlineDate=1762842158821, onlineDateStr=2025-11-11, pubDate=1746028800000, pubDateStr=2025-05-01, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1762842158821, onlineIssueDateStr=2025-11-11, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1762842158821, creator=13701087609, updateTime=1770195437842, updator=13701087609, issue=Issue{id=1195009883369091469, tenantId=1146029695717560320, journalId=1190317699101192196, year='2025', volume='60', issue='9', pageStart='893', pageEnd='1004', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1762842158405, creator=13701087609, updateTime=1762846632399, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1195028649066893312, tenantId=1146029695717560320, journalId=1190317699101192196, issueId=1195009883369091469, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1195028649071087617, tenantId=1146029695717560320, journalId=1190317699101192196, issueId=1195009883369091469, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=1000, endPage=1004, ext={EN=ArticleExt(id=1195009885357195847, articleId=1195009885118120517, tenantId=1146029695717560320, journalId=1190317699101192196, language=EN, title=Analysis of DRPs Identification and Intervention Effect in Patients with CKD3-5D by Resident Clinical Pharmacists, columnId=null, journalTitle=Chinese Pharmaceutical Journal, columnName=null, runingTitle=null, highlight=null, articleAbstract=

OBJECTIVE To explore the value of pharmaceutical care for patients with CKD3-5D by resident clinical pharmacists. METHODS Clinical pharmacists in the department of nephrology and three students formed a resident pharmacists team to develop standardized pharmaceutical care procedures(including admission medication reconciliation, doctor's order review, DRPs recognition, pharmaceutical care, medication education, discharge medication reconciliation, etc.) to provide pharmaceutical care for patients with 3-5D chronic kidney disease(CKD). The basic information, disease diagnosis and drug reorganization information of patients admitted to the department of nephrology of our hospital in 2024 were collected. The classification system based on the modified version of the European Foundation for Pharmaceutical Care Network(PCNE) was used to analyze the drug related problems(DRPs) of patients for assessment, intervention and statistical analysis. RESULTS A total of 141 patients were included in this study, and pharmacists found 54 DRPs, with an incidence of 38.3%. Among them, 36 cases(66.67%) were related to the effectiveness of treatment. Clinical pharmacists carried out 60 interventions, and the acceptance and complete implementation rate was 79.63%. The harmfulness grades of the 54 DRPs were as follows: 22 in grade E(40.74%), 16 in grade D(29.63%), 6 in grade C(11.11%), 6 in grade B(11.11%), and 4 in grade F(7.41%). CONCLUSION DRPs in patients with CKD3-5D are relatively common and harmful to some extent. Resident clinical pharmacists can identify and timely solve DRPs in patients with CKD3-5D through standardized pharmaceutical care, and assist physicians to ensure the safety, effectiveness and economy of drug use for patients.

, correspAuthors=Yong WANG, authorNote=null, correspAuthorsNote=null, copyrightStatement=null, copyrightOwner=null, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, authorCompany=null, fund=null, authors=null, authorsList=Yongfu HANG, Jie WANG, Wen ZHANG, Yingyi NIU, Deyu XU, Kun HU, Lei SHEN, Guoyuan LU, Jianguo ZHU, Chenrong HUANG, Yong WANG), CN=ArticleExt(id=1195009885684351562, articleId=1195009885118120517, tenantId=1146029695717560320, journalId=1190317699101192196, language=CN, title=驻科临床药师对慢性肾脏病3~5D期患者的药物相关问题识别及干预效果分析, columnId=1190352405612040510, journalTitle=中国药学杂志, columnName=论著, runingTitle=null, highlight=null, articleAbstract=

目的 探讨驻科临床药师对慢性肾脏病3~5D(CKD3~5D)期患者药学服务的价值。方法 肾内科临床药师和3名学员组成驻科药师团队,制定标准化药学服务流程[包括入院药物重整、医嘱审核、药物相关问题(drug related problems,DRPs)识别、药学监护、用药教育、出院药物重整等],对CKD3~5D期住院患者进行药学服务。统计2024年入住苏州大学附属第一医院肾内科患者的基本信息、疾病诊断和药物重整信息等,采用基于欧洲药学监护网络基金会(PCNE)分类改良版的分类系统对患者存在的DRPs进行评估、干预并进行统计分析。结果 本研究最终共纳入141例患者,药师共发现DRPs 54个,发生率38.3%。36条(66.67%)与治疗有效性有关,临床药师共进行了60次介入干预,接受介入方案并完全执行率为79.63%。54个DRPs危害性程度分级:E级22个(占40.74%),D级16个(占29.63%),C级6个(占11.11%),B级6个(占11.11%),F级4个(占7.41%)。结论 CKD3~5D患者发生DRPs较为常见且具有一定危害性,驻科临床药师通过标准化药学服务能够识别并及时解决CKD3~5D患者的DRPs,协助医师保障患者用药安全、有效、经济。

, correspAuthors=王永, authorNote=null, correspAuthorsNote=
*王永,男,学士,副主任药师 研究方向:医院药学Tel:(0512)67973021
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杭永付,男,硕士,副主任药师 研究方向:临床药学

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杭永付,男,硕士,副主任药师 研究方向:临床药学

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杭永付,男,硕士,副主任药师 研究方向:临床药学

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Curr Opin Nephrol Hypertens, 2011, 20(5):492-497., articleTitle=Polypharmacy and medication-related complications in the chronic kidney disease patient, refAbstract=null), Reference(id=1195061154591543557, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, doi=null, pmid=null, pmcid=null, year=2019, volume=74, issue=null, pageStart=625, pageEnd=629, url=null, language=null, rfNumber=[9], rfOrder=8, authorNames=DVOŘÁČKOVÁ E, RYCHLÍČKOVÁ J, PÁVEK P, journalName=Pharmazie, refType=null, unstructuredReference=DVOŘÁČKOVÁ E, RYCHLÍČKOVÁ J, PÁVEK P, et al. Analysis and management of drug related problems on a nephrology ward from a pharmacist's point of view[J]. Pharmazie, 2019, 74:625-629., articleTitle=Analysis and management of drug related problems on a nephrology ward from a pharmacist's point of view, refAbstract=null), Reference(id=1195061154675429639, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, doi=null, pmid=null, pmcid=null, year=2023, volume=44, issue=6, pageStart=642, pageEnd=648, url=null, language=null, rfNumber=[10], rfOrder=9, authorNames=LAN F, YANG L Y, ZHANG X Y, journalName=World Clin Drug(世界临床药物), refType=null, unstructuredReference=LAN F, YANG L Y, ZHANG X Y, et al. Advances on research and clinical application of roxadustat[J]. World Clin Drug(世界临床药物), 2023, 44(6):642-648., articleTitle=Advances on research and clinical application of roxadustat, refAbstract=null)], funds=[Fund(id=1195061153496830193, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, awardId=ZDXK202247, language=CN, fundingSource=江苏省医学重点学科项目资助(ZDXK202247), fundOrder=null, country=null), Fund(id=1195061153698156786, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, awardId=SKYXD2022017, language=CN, fundingSource=苏州市科技发展计划指导性项目资助(SKYXD2022017), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1195061147712884847, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, xref=1, ext=[AuthorCompanyExt(id=1195061147717079152, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, companyId=1195061147712884847, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1 Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou 215000, China), AuthorCompanyExt(id=1195061147725467761, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, companyId=1195061147712884847, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1 苏州大学附属第一医院药学部, 江苏 苏州 215000)]), AuthorCompany(id=1195061147788382322, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, xref=2, ext=[AuthorCompanyExt(id=1195061147821936755, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, companyId=1195061147788382322, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2 Department of Pharmacy, Changshu No.1 People's Hospital, Suzhou 215500, China), AuthorCompanyExt(id=1195061147830325364, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, companyId=1195061147788382322, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2 常熟市第一人民医院药学部, 江苏 苏州 215500)]), AuthorCompany(id=1195061147993903221, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, xref=3, ext=[AuthorCompanyExt(id=1195061148002291830, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, companyId=1195061147993903221, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=3 Department of Pharmacy, Nanjing First Hospital Nanjing Medical University, Nanjing 210000, China), AuthorCompanyExt(id=1195061148010680439, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, companyId=1195061147993903221, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=3 南京市第一医院药学部, 南京 210000)]), AuthorCompany(id=1195061148077789304, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, xref=4, ext=[AuthorCompanyExt(id=1195061148081983609, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, companyId=1195061148077789304, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=4 Department of Pharmacy, Suzhou Ninth People's Hospital, Suzhou 215200, China), AuthorCompanyExt(id=1195061148090372218, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, companyId=1195061148077789304, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=4 苏州市第九人民医院药学部, 江苏 苏州 215200)]), AuthorCompany(id=1195061148144898171, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, xref=5, ext=[AuthorCompanyExt(id=1195061148153286780, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, companyId=1195061148144898171, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=5 Department of Nephrology, The First Affiliated Hospital of Soochow University, Suzhou 215000, China), AuthorCompanyExt(id=1195061148161675389, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, companyId=1195061148144898171, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=5 苏州大学附属第一医院肾内科, 江苏 苏州 215000)])], figs=[ArticleFig(id=1195061152452448480, tenantId=1146029695717560320, journalId=1190317699101192196, articleId=1195009885118120517, language=EN, label=null, caption=null, figureFileSmall=null, figureFileBig=null, tableContent=
DRPs的类别 数量/例 比例/%
P1治疗有效性 36 66.67
P1.1合理使用药物后治疗无效 2 3.70
P1.2治疗效果不佳 20 37.04
P1.3有未治疗的症状或适应证 14 25.93
P2治疗安全性 7 12.96
P2.1(可能)发生药物不良事件 7 12.96
P3其他 11 20.37
P3.2不必要的药物治疗 4 7.41
P3.3不确定的问题或抱怨(请仅当无法明确分类时使用) 7 12.96
总计 54 100
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慢性肾脏病(CKD)3~5D期住院患者发生药物相关问题(DRPs)的类别

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DRPs的类别 数量/例 比例/%
P1治疗有效性 36 66.67
P1.1合理使用药物后治疗无效 2 3.70
P1.2治疗效果不佳 20 37.04
P1.3有未治疗的症状或适应证 14 25.93
P2治疗安全性 7 12.96
P2.1(可能)发生药物不良事件 7 12.96
P3其他 11 20.37
P3.2不必要的药物治疗 4 7.41
P3.3不确定的问题或抱怨(请仅当无法明确分类时使用) 7 12.96
总计 54 100
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原因的类别 数量/例 比例/%
处方方面 38 65.52
C1药物选择 13 22.41
C1.2无指征用药 1 1.72
C1.4药物重复使用(药理作用相同或活性成分相同) 2 3.45
C1.5尽管存在适应证,未给予或没有给予完整的药物治疗 10 17.24
C3剂量选择 24 41.38
C3.1药物剂量过低 12 20.69
C3.2单活性成分药物剂量过高 5 8.62
C3.3给药频次不足 5 8.62
C3.4给药频次过多 2 3.45
C4治疗疗程 1 1.72
C4.2疗程过长 1 1.72
使用方面 15 25.86
C6.医疗专业人员相关 4 6.90
C6.2医疗专业人员给予的药物剂量不足 1 1.72
C6.3医疗专业人员给予的药物过量 1 1.72
C6.4医疗专业人员未给予药物 2 3.45
C7患者相关 11 18.97
C7.1患者因各种原因故意减量服药或根本未服药 1 1.72
C7.7患者服药时间或服药间隔不适当 10 17.24
其他方面 5 8.62
C8患者治疗地点转换相关 3 5.17
C8.1药物重整问题 3 5.17
C9其他 2 3.45
C9.2其他原因;详细说明 1 1.72
C9.3没有明显的问题 1 1.72
总计 58 100
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CKD3~5D期住院患者发生DRPs的原因

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原因的类别 数量/例 比例/%
处方方面 38 65.52
C1药物选择 13 22.41
C1.2无指征用药 1 1.72
C1.4药物重复使用(药理作用相同或活性成分相同) 2 3.45
C1.5尽管存在适应证,未给予或没有给予完整的药物治疗 10 17.24
C3剂量选择 24 41.38
C3.1药物剂量过低 12 20.69
C3.2单活性成分药物剂量过高 5 8.62
C3.3给药频次不足 5 8.62
C3.4给药频次过多 2 3.45
C4治疗疗程 1 1.72
C4.2疗程过长 1 1.72
使用方面 15 25.86
C6.医疗专业人员相关 4 6.90
C6.2医疗专业人员给予的药物剂量不足 1 1.72
C6.3医疗专业人员给予的药物过量 1 1.72
C6.4医疗专业人员未给予药物 2 3.45
C7患者相关 11 18.97
C7.1患者因各种原因故意减量服药或根本未服药 1 1.72
C7.7患者服药时间或服药间隔不适当 10 17.24
其他方面 5 8.62
C8患者治疗地点转换相关 3 5.17
C8.1药物重整问题 3 5.17
C9其他 2 3.45
C9.2其他原因;详细说明 1 1.72
C9.3没有明显的问题 1 1.72
总计 58 100
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介入方案类别 数量/例 比例/%
药师层面 5 8.33
I0.1未介入 5 8.33
医师层面 28 46.67
I1.1仅告知医师 21 35.00
I1.3提供介入方案给医师 7 11.67
患者层面 4 6.67
I2.1患者(药物)咨询 2 3.33
I2.3建议患者咨询医师 1 1.67
I2.4与患者家属/看护者会谈 1 1.67
经医师同意后药物层面 23 38.33
I3.1药物调整为…. 3 5.00
I3.2剂量调整为…. 7 11.67
I3.4使用方法调整为…. 9 15.00
I3.5停用药物 1 1.67
I3.6启用新药物 3 5.00
总计 60 100
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CKD3~5D期住院患者DRPs的介入方案类别

, figureFileSmall=null, figureFileBig=null, tableContent=
介入方案类别 数量/例 比例/%
药师层面 5 8.33
I0.1未介入 5 8.33
医师层面 28 46.67
I1.1仅告知医师 21 35.00
I1.3提供介入方案给医师 7 11.67
患者层面 4 6.67
I2.1患者(药物)咨询 2 3.33
I2.3建议患者咨询医师 1 1.67
I2.4与患者家属/看护者会谈 1 1.67
经医师同意后药物层面 23 38.33
I3.1药物调整为…. 3 5.00
I3.2剂量调整为…. 7 11.67
I3.4使用方法调整为…. 9 15.00
I3.5停用药物 1 1.67
I3.6启用新药物 3 5.00
总计 60 100
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介入方案接受情况 数量/例 比例/%
介入被接受 46 85.19
A1.1接受介入方案并完全执行 43 79.63
A1.2接受介入方案,部分执行 1 1.85
A1.3接受介入方案,但并未执行 2 3.70
介入未被接受 1 1.85
A2.2未接受介入方案:不赞同 1 1.85
其他 7 12.96
A3.1提出介入方案,但不清楚是否被接受 2 3.70
A3.2未提出介入方案 5 9.26
总计 54 100
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CKD3~5D期住院患者DRPs的介入方案接受情况

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介入方案接受情况 数量/例 比例/%
介入被接受 46 85.19
A1.1接受介入方案并完全执行 43 79.63
A1.2接受介入方案,部分执行 1 1.85
A1.3接受介入方案,但并未执行 2 3.70
介入未被接受 1 1.85
A2.2未接受介入方案:不赞同 1 1.85
其他 7 12.96
A3.1提出介入方案,但不清楚是否被接受 2 3.70
A3.2未提出介入方案 5 9.26
总计 54 100
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驻科临床药师对慢性肾脏病3~5D期患者的药物相关问题识别及干预效果分析
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杭永付 1 , 王洁 2 , 张雯 3 , 钮颖祎 4 , 徐德宇 5 , 胡坤 5 , 沈蕾 5 , 卢国元 5 , 朱建国 1 , 黄晨蓉 1 , 王永 1, *
中国药学杂志 | 论著 2025,60(9): 1000-1004
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中国药学杂志 | 论著 2025, 60(9): 1000-1004
驻科临床药师对慢性肾脏病3~5D期患者的药物相关问题识别及干预效果分析
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杭永付1, 王洁2, 张雯3, 钮颖祎4, 徐德宇5, 胡坤5, 沈蕾5, 卢国元5, 朱建国1, 黄晨蓉1, 王永1, *
作者信息
  • 1 苏州大学附属第一医院药学部, 江苏 苏州 215000
  • 2 常熟市第一人民医院药学部, 江苏 苏州 215500
  • 3 南京市第一医院药学部, 南京 210000
  • 4 苏州市第九人民医院药学部, 江苏 苏州 215200
  • 5 苏州大学附属第一医院肾内科, 江苏 苏州 215000

    • 杭永付,男,硕士,副主任药师 研究方向:临床药学

通讯作者:

*王永,男,学士,副主任药师 研究方向:医院药学Tel:(0512)67973021
Analysis of DRPs Identification and Intervention Effect in Patients with CKD3-5D by Resident Clinical Pharmacists
Yongfu HANG1, Jie WANG2, Wen ZHANG3, Yingyi NIU4, Deyu XU5, Kun HU5, Lei SHEN5, Guoyuan LU5, Jianguo ZHU1, Chenrong HUANG1, Yong WANG1, *
Affiliations
  • 1 Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou 215000, China
  • 2 Department of Pharmacy, Changshu No.1 People's Hospital, Suzhou 215500, China
  • 3 Department of Pharmacy, Nanjing First Hospital Nanjing Medical University, Nanjing 210000, China
  • 4 Department of Pharmacy, Suzhou Ninth People's Hospital, Suzhou 215200, China
  • 5 Department of Nephrology, The First Affiliated Hospital of Soochow University, Suzhou 215000, China
出版时间: 2025-05-01 doi: 10.11669/cpj.2025.09.013
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摘要
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目的 探讨驻科临床药师对慢性肾脏病3~5D(CKD3~5D)期患者药学服务的价值。方法 肾内科临床药师和3名学员组成驻科药师团队,制定标准化药学服务流程[包括入院药物重整、医嘱审核、药物相关问题(drug related problems,DRPs)识别、药学监护、用药教育、出院药物重整等],对CKD3~5D期住院患者进行药学服务。统计2024年入住苏州大学附属第一医院肾内科患者的基本信息、疾病诊断和药物重整信息等,采用基于欧洲药学监护网络基金会(PCNE)分类改良版的分类系统对患者存在的DRPs进行评估、干预并进行统计分析。结果 本研究最终共纳入141例患者,药师共发现DRPs 54个,发生率38.3%。36条(66.67%)与治疗有效性有关,临床药师共进行了60次介入干预,接受介入方案并完全执行率为79.63%。54个DRPs危害性程度分级:E级22个(占40.74%),D级16个(占29.63%),C级6个(占11.11%),B级6个(占11.11%),F级4个(占7.41%)。结论 CKD3~5D患者发生DRPs较为常见且具有一定危害性,驻科临床药师通过标准化药学服务能够识别并及时解决CKD3~5D患者的DRPs,协助医师保障患者用药安全、有效、经济。

驻科临床药师  /  慢性肾脏病  /  药物重整  /  药物相关问题

OBJECTIVE To explore the value of pharmaceutical care for patients with CKD3-5D by resident clinical pharmacists. METHODS Clinical pharmacists in the department of nephrology and three students formed a resident pharmacists team to develop standardized pharmaceutical care procedures(including admission medication reconciliation, doctor's order review, DRPs recognition, pharmaceutical care, medication education, discharge medication reconciliation, etc.) to provide pharmaceutical care for patients with 3-5D chronic kidney disease(CKD). The basic information, disease diagnosis and drug reorganization information of patients admitted to the department of nephrology of our hospital in 2024 were collected. The classification system based on the modified version of the European Foundation for Pharmaceutical Care Network(PCNE) was used to analyze the drug related problems(DRPs) of patients for assessment, intervention and statistical analysis. RESULTS A total of 141 patients were included in this study, and pharmacists found 54 DRPs, with an incidence of 38.3%. Among them, 36 cases(66.67%) were related to the effectiveness of treatment. Clinical pharmacists carried out 60 interventions, and the acceptance and complete implementation rate was 79.63%. The harmfulness grades of the 54 DRPs were as follows: 22 in grade E(40.74%), 16 in grade D(29.63%), 6 in grade C(11.11%), 6 in grade B(11.11%), and 4 in grade F(7.41%). CONCLUSION DRPs in patients with CKD3-5D are relatively common and harmful to some extent. Resident clinical pharmacists can identify and timely solve DRPs in patients with CKD3-5D through standardized pharmaceutical care, and assist physicians to ensure the safety, effectiveness and economy of drug use for patients.

resident clinical pharmacist  /  chronic kidney disease  /  drug reconciliation  /  drug related problem
杭永付, 王洁, 张雯, 钮颖祎, 徐德宇, 胡坤, 沈蕾, 卢国元, 朱建国, 黄晨蓉, 王永. 驻科临床药师对慢性肾脏病3~5D期患者的药物相关问题识别及干预效果分析. 中国药学杂志, 2025 , 60 (9) : 1000 -1004 . DOI: 10.11669/cpj.2025.09.013
Yongfu HANG, Jie WANG, Wen ZHANG, Yingyi NIU, Deyu XU, Kun HU, Lei SHEN, Guoyuan LU, Jianguo ZHU, Chenrong HUANG, Yong WANG. Analysis of DRPs Identification and Intervention Effect in Patients with CKD3-5D by Resident Clinical Pharmacists[J]. Chinese Pharmaceutical Journal, 2025 , 60 (9) : 1000 -1004 . DOI: 10.11669/cpj.2025.09.013
正文
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慢性肾脏病(chronic kidney disease,CKD)是由各种原因引起的慢性肾脏结构或功能障碍,通过治疗可以延缓病程的疾病[1]。近年来,我国CKD的发病率也呈明显上升趋势,占比9.4%~12.1%[2]。根据改善全球肾脏病预后组织(KDIGO)指南,按照估算肾小球滤过率(eGFR)将CKD分为5期,其中3~5D期[CKD3期:eGFR 30~59 mL·min-1·(1.73 m2)-1,CKD4期:eGFR15~30 mL·min-1·(1.73 m2)-1,CKD5期:eGFR<15 mL·min-1·(1.73 m2)-1,CKD5D期:透析期]患者常合并或并发多种疾病,如高血压、高尿酸血症、肾性贫血及高磷血症等,用药情况复杂,极易出现药物相关问题(drug related problems,DRPs),是临床医师和药师的重点关注对象。
临床药师驻科是指临床药师工作场所从医院药剂科(或药学部)转移至各临床病区,与临床医师共同查房、讨论治疗方案,给出用药建议,监护治疗过程,判断药品不良反应(adverse drug reaction,ADR),并协助医师诊疗[3]。国家卫健委、国家中医药局在《关于开展全面提升医疗质量行动(2023—2025年)的通知》中明确提出提升合理用药水平,对不合理用药行为及时采取干预措施。在儿科等重点科室配备驻科药师,参与药物治疗管理[4]。驻科临床药师是国家重点推行的工作之一,也是未来临床药师的发展方向,目前已发布多项药学服务规范[5],但驻科临床药师的工作模式尚未统一,仍处于探索阶段。笔者结合前期CKD患者药学服务模式,制定驻科临床药师工作内容,规范工作流程,提出“病区负责制”的工作模式,根据CKD分期进行分级药学监护。本研究以CKD3~5D期患者为研究对象,探讨该工作模式的效果。
1 资料与方法
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1.1 资料来源及纳排标准
2024年入住苏州大学附属第一医院肾内科患者。
纳入标准:①诊断为CKD3~5D期,包括血液透析和腹膜透析;②使用药物≥1种;③同意接受驻科“病区负责制”模式的药学服务。
排除标准:①统计中涉及的重要数据缺失(如干预指标等);②危重症无法沟通的患者;③存在医患矛盾的患者。
1.2 驻科“病区负责制”模式
肾内科临床药师带领3名学员组成药师团队,作为医疗团队的重要成员,参与临床诊疗工作。专科药师负责整个病区所有患者的DRPs。每位学员分配负责的床位。制定规范工作流程,进行住院全程药学服务,包括入院药物重整、医嘱审核、药学监护、药学会诊、用药教育、出院药物重整等。全程识别DRPs、分析原因、干预并记录。学员发现的DRPs汇报给专科药师,由专科药师评估并进一步处理。以每个DRP为目标导向,基于欧洲药学监护网络基金会(Pharmaceutical Care Network Europe,PCNE)分类系统构建了“问题(P)-原因(C)-潜在危害性程度评估(ME)-干预(I)-接受度(A)-状态(O)”6方面的改良版DRPs分类系统,形成“发现问题-分析问题-评估问题-解决问题-随访问题-记录问题”这一工作循环流程。
1.3 方法
对入组患者进行药学服务,运用前期改良版DRPs分类系统对发现的DRPs进行分类,统计分析入组患者的基本信息,DRPs分类系统分析每个DRPs,统计干预情况。运用SPSS 22.0版统计软件进行数据处理分析。潜在危害性程度采用用药错误的四层九级分类标准进行评估[1],并统计各级占比。
2 结果
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2.1 基本信息
本研究共纳入141例CKD3~5D期患者。男性82例,女性59例,平均年龄(55.77±14.05)岁,年龄≥65岁老年人40例(占28.37%)。CKD3期44例(占31.20%),CKD4期25例(占17.73%),CKD5期30例(占21.28%),CKD5D期42例(占29.79%)。合并高血压113例(占80.14%),肾性贫血74例(占52.48%),高尿酸血症45例(占31.91%),高脂血症43例(占30.50%),高磷血症33例(占23.40%),糖尿病32例(占22.70%)。
2.2 CKD3~5D期患者发生DRPs情况
2.2.1 DRPs的类别及原因
141例次患者中共发生了54个DRPs,发生率38.3%。大部分与治疗有效性有关,共36条(占66.67%),与治疗安全性有关的7条(占12.96%),其他情况的11条(占20.37%),见表1。54个DRPs原因方面按问题分类可分为58条,处方方面38条(占65.52%),剂量过低最多(占20.69%),其次药物选择方面有适应证但未给予充分治疗(占17.24%)。使用方面15条(占25.86%),患者相关的最多(占18.97%),主要是服药时间或服药间隔不适当(占17.24%)。其他方面5条(占8.62%),见表2。
2.2.2 DRPs潜在危害性评估
对发生的54个DRPs进行潜在危害性评估,发生次数依次为:E级22个(占40.74%),D级16个(占29.63%),C级6个(占11.11%),B级6个(占11.11%),F级4个(占7.41%)。E级+F级26个(占48.15%)。
2.2.3 DRPs的介入方案类别及接受情况
针对CKD3~5D期患者发生的DRPs,临床药师共进行了60次介入干预(表3),医师层面28条(46.67%),药物层面23条(38.33%),药师层面5条(8.33%),患者层面4条(6.67%)。通过临床药师的积极干预,方案接受并完全执行率为79.63%(表4)。
3 讨论
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3.1 CKD3~5D患者DRPs发生率
本研究CKD3~5D期患者最常见的合并症是高血压(80.14%)和肾性贫血(占52.48%),与其他研究相似[6]。该类患者服药品种较多,DRPs和ADR风险随之增加。国外一项系统评价报道CKD患者DRPs的发生率从12%~87%不等,45.95%的CKD住院患者经历了DRPs[7]。国内一项回顾研究发现CKD住院患者不适当处方的发生率为15.18%[6]。本研究中CKD3~5D住院患者DRPs发生率为38.3%,提示DRPs在该类住院患者中是普遍现象,这也为驻科临床药师的必要性提供了数据支持。
本研究中54个DRPs大部分与治疗有效性有关,共36条(66.67%)。这提示药师需要把疗效指标放在首位,关注疗效不佳的原因,其次不能忽略部分未进行治疗的适应证。与治疗安全性有关的DRPs共7条,占12.96%,易出现ADR甚至严重的药害事件等[8]需要引起医务人员重视。安全性方面剂量调整案例:患者男性,56岁。诊断:肾病综合征,2型糖尿病肾病,高血压,高脂血症。就诊时医嘱:二甲双胍0.5 g po bid,达格列净10 mg po qd,硝苯地平控释片30 mg po bid,缬沙坦胶囊160 mg po qd,非奈利酮片10 mg po bid,阿托伐他汀钙片20 mg po qn,氯吡格雷75 mg po qd,复方α-酮酸片2.52 g po tid。患者eGFR 46 mL·min-1·(1.73 m2)-1,感冒予奥司他韦75 mg po bid抗病毒治疗。药师发现对于30 mL·min-1·(1.73 m2)-1<肌酐清除率(creatinine clearance rate, CCr)<60 mL·min-1·(1.73 m2)-1的患者推荐使用剂量减少为每次30 mg bid,共5 d。医嘱给药量偏大,结合剂型问题建议减量75 mg po qd服用。医师采纳并执行(DRPs类别P2.1,原因C3.4,干预I1.1,问题全部解决A1.1,危害等级D)。
3.2 DRPs发生的原因
原因中处方方面(占65.52%)是主要原因。“药物选择”(22.41%)和“剂量选择”(41.38%)是主要方面(占63.79%)。“尽管存在适应证,未给予或没有给予完整的药物治疗”(17.24%)和“药物剂量太低”(20.69%)占比最大。Dvo $\stackrel{̬}{r}$á $\stackrel{̬}{c}$ková等[9]研究发现最常见的DRPs是未经治疗的适应证(27.18%)和剂量过低(20.81%),与本研究的结果相似。药物使用方面(占25.86%)是第二大原因。有17.24%的患者服药时间或服药间隔不适当,这其中药物之间的相互作用较多,如罗沙司他与司维拉姆同时服用,可导致罗沙司他曲线下面积(AUC)降低67%,最大血药浓度(cmax)下降 66%[10]。应在磷结合剂、口服铁剂、含镁/铝抗酸剂或其他含多价阳离子药物和矿物质补充剂使用前后至少间隔1 h服用罗沙司他。因此,驻科临床药师用药教育应注重合理安排好患者给药间隔,保证患者正确服用。疗效方面给药间隔案例:患者女性,72岁。诊断:CKD5期,腹膜透析,高血压,糖尿病。入院后患者自诉早餐后同时服用瑞格列奈、复方α-酮酸片、琥珀酸亚铁缓释片、罗沙司他等。查血红蛋白(hemoglobin,Hb)88 g·L-1。遂教育患者并合理安排服药时间:瑞格列奈早餐前30 min,复方α-酮酸片餐中,下午2点服用琥珀酸亚铁缓释片,晚饭后2 h服用罗沙司他。患者调整了服药时间,随访2次后出院时复测Hb 96 g·L-1(DRPs类别P1.2,原因C7.7,干预I 3.4,问题全部解决A1.1,危害等级E)。
3.3 DRPs的危害性评价
DRPs危害性评价中需要注意的是E级+F级26个(占48.15%),对患者已造成危害,临床药师需要积极干预。较多见的是血红蛋白、血磷等临床指标不达标,多和药物不良相互作用有关,也有对患者造成暂时性伤害或导致住院时间延长,特别需要引起临床重视。危害性方面F级案例:患者男性,54岁,诊断:CKD5期,腹膜透析,腹膜透析相关性腹膜炎,继发性甲状旁腺功能亢进,肾性贫血,痛风,肝硬化。患者入院时测血凝:凝血酶原时间(prothrombin time,PT)13.4 s,活化部分凝血酶原时间(activated partial thromboplastin time,APTT)31.9 s,因腹透相关性腹膜炎开始使用头孢哌酮舒巴坦1.5 g ivgtt q12h,10 d后复测血凝:PT 47 s,APTT 107.2 s。临床药师分析凝血功能障碍很可能和头孢哌酮舒巴坦有关,遂建议停用头孢哌酮舒巴坦,建议更改为莫西沙星氯化钠注射液0.4 g ivgtt qd,继观。13 d后复测凝血功能:PT 12.6 s,APTT 31 s。基本恢复正常(DRPs类别为P2.1,原因是C9.2,干预是I1.3,问题全部解决A1.1,危害等级F)。
3.4 驻科“病区负责制”模式减少DRPs的价值
针对DRPs,临床药师共提出了60条干预建议,79.63%的干预被接受并完全执行,说明医务人员和患者对临床药师提出的干预接受程度较高,从侧面也反映了药师的建议专业性得到认可。但也有1.85%的干预未被接受,这可能与医师综合患者病情或其他考虑,与临床药师意见不一致有关。另外有3.70%的干预得到赞同但并未执行。可能与医师工作繁忙,被其他重要的事耽搁了有关,这也是药师在临床上时常碰到的问题,提示药师在干预后仍应注意加强随访工作。本研究中临床药师发现了54个DRPs,提供了60次干预,防范并解决了80%的DRPs,减少了临床用药风险,节省了医疗负担。
基金
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  • 江苏省医学重点学科项目资助(ZDXK202247)
  • 苏州市科技发展计划指导性项目资助(SKYXD2022017)
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参考文献 引证文献
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2025年第60卷第9期
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doi: 10.11669/cpj.2025.09.013
  • 接收时间：2024-12-31
  • 首发时间：2025-11-11
  • 出版时间：2025-05-01
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  • 收稿日期：2024-12-31
基金
江苏省医学重点学科项目资助(ZDXK202247)
苏州市科技发展计划指导性项目资助(SKYXD2022017)
作者信息
    1 苏州大学附属第一医院药学部, 江苏 苏州 215000
    2 常熟市第一人民医院药学部, 江苏 苏州 215500
    3 南京市第一医院药学部, 南京 210000
    4 苏州市第九人民医院药学部, 江苏 苏州 215200
    5 苏州大学附属第一医院肾内科, 江苏 苏州 215000

通讯作者:

*王永,男,学士,副主任药师 研究方向:医院药学Tel:(0512)67973021
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
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