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| 研究生： |
張筱琳 Chang, Hsiao-Lin |
|---|---|
| 論文名稱： |
建立肝臟移植病患之藥事照護模式 Developing a Pharmaceutical Care Model in Liver Transplant Patients |
| 指導教授： |
林毅志
Lin, Yih-Jyh 廖麗香 Liao, Li-Hsiang 高雅慧 Kao, Yea-Huei |
| 學位類別： |
碩士 Master |
| 系所名稱： |
醫學院 - 臨床藥學研究所 Institute of Clinical Pharmacy |
| 論文出版年： | 2005 |
| 畢業學年度： | 93 |
| 語文別： | 中文 |
| 論文頁數： | 176 |
| 中文關鍵詞： | 肝臟移植，免疫抑制劑，衛教與諮詢，服藥順從性，藥事服務 |
| 外文關鍵詞： | clinical pharmacy services, medication adherence, patient education, immunosuppressive agents, Liver transplantation |
| 相關次數： | 點閱：114 下載：0 |
| 分享至: |
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背景
肝臟移植是末期肝病患者唯一有效的治療方式。移植後病患須長期服用免疫抑制劑，如果對免疫抑制劑服藥順從性不佳，可能造成移植器官功能喪失或死亡；如何提高病患對免疫抑制劑的服藥順從性相對重要，甚至影響著移植成敗。另外，病患因長期服用免疫抑制劑以及可能需額外用藥治療相關併發症，如何預防及處理藥物交互作用、藥物不良反應等問題也是重要的議題。藥師可藉由病患衛教，幫助病患瞭解服藥順從性的重要性及正確用藥；協助簡化用藥以提升病患服藥順從性；同時也可以藉由參與移植小組的工作，協助預防及處理相關的藥物交互作用、藥物不良反應及提供合理的治療建議。
研究目的
提供肝臟移植病患疾病與用藥知識衛教與諮詢，以提升病患對免疫抑制劑的服藥順從性和對疾病與用藥知識的認知；提供肝臟移植病患與移植醫療團隊相關的藥事服務。
研究對象
在成大醫院追蹤治療之肝臟移植病患，願意接受藥師諮詢者。
研究方法
研究期間由西元2004年12月至2005年4月，使用藥粒計算、監測藥物血中濃度與病患自我評估表來評估服藥順從性。介入增加服藥順從性的方法，包括藥物資訊提供，使用藥盒，病患訪談，肝臟移植疾病與用藥知識衛教。臨床藥事服務項目包括確立病患病史、處理用藥相關問題、提供藥物交互作用資訊、評估與處理藥物不良反應，並提供移植團隊相關用藥建議。
研究結果
研究期間共8位肝臟移植病患接受諮詢。諮詢後病患對免疫抑制劑服藥順從性顯著提升；calcineurin inhibitors（CNIs）服藥順從率由87.8 % 提升為99 % （P = 0.043），mycophenolate mofetil（MMF）服藥順從率由82.4 % 提升為100 % （P = 0.043）。病患對疾病與用藥知識的認知也有顯著的進步（P = 0.011）。藥事服務介入件數共39件，80 % 為醫師所接受；藥事介入以藥物頻次與藥物選擇為主，介入藥物類別以免疫抑制劑與抗生素最多。藥物不良反應評估包括CNIs引起的腎毒性和神經毒性，與MMF引起的腸胃道副作用等。提供藥物資訊包括巨細胞病毒感染的預防策略、藥物血中濃度監測、肝臟移植病患statins的選用以及CNIs 併用ACEIs或ARBs時之血鉀控制策略等。
結論
藥師介入可以提升肝臟移植病患的服藥順從性及對疾病與用藥知識的認知；對肝臟移植病患的治療成效（patient outcome）具有潛在正向的影響。藥師提供臨床藥事服務廣為肝臟移植小組所接受且對病患照護有實質的助益。
Background
Liver transplantation is a life-saving procedure for patients with severe hepatic disease who have no other medical option. Transplant patients require long-term immunosuppressive therapy to prevent rejection. However, nonadherence to immunosuppressive therapy is a leading cause of graft rejection and may lead to graft loss or death. Meanwhile, transplant patients take multiple medications to treat concomitant disease; therefore, drug interactions, adverse drug reactions and optimal drug therapy are important issues. Pharmacists can educate the patient about the importance of medication adherence and help adjust the medication regimens to improve adherence.
Objective
To promote immunosuppressive therapy adherence and knowledge about medications and illness by providing education and counseling in liver transplant patients.
Subjects
Inpatient and outpatient liver transplant patients who had agreed to receive pharmacist’s counseling in the liver transplant center, NCKU.
Methods
From December 2004 to April 2005, we assessed adherence by pill count, calcineurin inhibitors’ levels and self-report form. A prospective evaluation of the patients’ knowledge about medications and illness was conducted through questionnaires. The pharmacist’s interventions were performed through interviewing with the patients and providing education and conseling on medications and illness related to liver transplantation. Besides, pillbox was used to improve medication adherence. The pharmacist also provided clinical services to the liver transplant team to optimize the medical therapy, which included reviewing patients’ medication profile, recommending regimen adjustment, evaluating adverse effects and drug interactions, and providing drug information.
Results
There were eight liver transplant patients recruited. The adherence rate (AR) of calcineurin inhibitors (CNIs) was increased from 87.8 % to 99 % after intervention (P = 0.043), and AR of mycophenolate mofetil （MMF）was also significantly improved (82.4 % vs. 100 %, P = 0.043). After education, the patients’ knowledge about immunosuppressive medications and illness was significantly improved (P = 0.011). During five months period, 39 pharmacotherapy recommendations were provided and 80 % were accepted. The major recommendations involved on medical therapy were related to dosage adjustment and medication selection, with immunosuppressive agents and antibiotics involved most frequently. The pharmacist also evaluated and monitored the adverse drug reactions of CNIs-induced nephrotoxicity and neurotoxicity and mycophenolate mofetil-induced diarrhea. With regard to the drug information services, the content included Cytomegalovirus prophylaxis strategy, therapeutic drug monitoring of CNIs, and statins selections in liver transplant patients.
Conclusion
The pharmacist intervention significantly improved medication adherence and knowledge in liver transplant patients. The pharmacist’s services were well recognized and appreciated by the team and had a positive impact on patient care.
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